Sigmoidectomy and anastomosis is also not required.

We are asked about the management of a very common pathology, diverticulitis. And we are asked about the different therapeutic options depending on how advanced it is. The correct answer is 1, it does not meet the criteria to require drainage by guided puncture (the abscess is not larger than 5-6 cm). Discharge colostomy in this case makes no sense whatsoever, since it is not a question of solving an obstructive condition. Drainage by laparoscopic surgery is not indicated in this case. It could be indicated in the absence of the possibility of percutaneous drainage after failure of conservative treatment, although it is a very controversial option at this time. Sigmoidectomy and anastomosis is also not required. In a high number of cases, after the resolution of the symptoms, the outbreaks are reduced and they can be prevented with diet and hygienic dietary habits.

We are asked about the management of a very common pathology, diverticulitis. And we are asked about the different therapeutic options depending on how advanced it is. [HIDDEN], it does not meet the criteria to require drainage by guided puncture (the abscess is not larger than 5-6 cm). Discharge colostomy in this case makes no sense whatsoever, since it is not a question of solving an obstructive condition. Drainage by laparoscopic surgery is not indicated in this case. It could be indicated in the absence of the possibility of percutaneous drainage after failure of conservative treatment, although it is a very controversial option at this time. Sigmoidectomy and anastomosis is also not required. In a high number of cases, after the resolution of the symptoms, the outbreaks are reduced and they can be prevented with diet and hygienic dietary habits.

An 80-year-old woman comes to the emergency room with abdominal pain starting in the epigastrium and radiating later to the left iliac fossa. An abdominal CT scan is performed, showing inflammation in the walls of the sigma and mesenteric abscess of 2 cm. The treatment of choice is:

Admission to the ward with absolute diet and broad-spectrum antibiotic treatment.

Urgent surgery with sigmoidectomy and colorectal anastomosis.

Danish national guidelines for treatment of diverticular disease.

In order to elaborate evidence-based, national Danish guidelines for the treatment of diverticular disease the literature was reviewed concerning the epidemiology, staging, diagnosis and treatment of diverticular disease in all its aspects.  The presence of colonic diverticula, which is considered to be a mucosal herniation through the intestinal muscle wall, is inversely correlated to the intake of dietary fibre. Other factors in the genesis of diverticular disease may be physical inactivity, obesity, and use of NSAIDs or acetaminophen. Diverticulosis is most common in Western countries with a prevalence of 5% in the population aged 30-39 years and 60% in the part of the population > 80 years. The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5-4/100,000. Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis. Complicated diverticulitis is staged by the Hinchey classification 1-4 (1: mesocolic/pericolic abscess, 2: pelvic abscess, 3: purulent peritonitis, 4: faecal peritonitis).  Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and/or CRP; but the clinical diagnosis is not sufficiently precise. Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey. The distinction between Hinchey 3 and 4 is done by laparoscopy or, when not possible, by laparotomy.  Uncomplicated diverticulitis is treated by conservative means. There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis, but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection.  Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics. When the abscess is < 3 cm in diameter, drainage may be unnecessary, and only antibiotics should be instituted.   The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies: The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or, alternatively, resection of the sigmoid with primary anastomosis. Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease. Evidence so far for the lavage regime is promising, comparing favourably with resection strategies, but lacking in solid proof by randomized, controlled investigations.  In recent years, morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities. Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed. Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures, since prophylactic resection of the sigmoid, evaluated from present evidence, confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society. Any recommendation for routine resection following multiple cases of diverticulitis should await results of randomized studies.  Laparoscopic resection is preferred in case of need for elective surgery. When malignancy is ruled out preoperatively, a sigmoid resection with preservation of the inferior mesenteric artery, oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended.  Fistulae to bladder or vagina, or stenosis of the colon may be dealt with according to symptoms and comorbidity. Resection of the diseased segment of colon is preferred when possible and safe; alternatively, a diverting stoma can be the best solution.

Diverticulitis

Antibiotics Mild uncomplicated diverticulitis without systemic inflammation should not be treated with antibiotics. For mild, uncomplicated, and non-purulent cases of acute diverticulitis, symptomatic treatment, IV fluids, and bowel rest have no worse outcome than surgical intervention in the short and medium term, and appear to have the same outcomes at 24 months. With abscess confirmed by CT scan, some evidence and clinical guidelines tentatively support the use of oral or IV antibiotics for smaller abscesses (<5 cm) without systemic inflammation, but percutaneous or laparoscopic drainage may be necessary for larger abscesses (>5 cm). Emergency surgery is required for perforated diverticulitis with peritonitis.

Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment.

In patients presenting with acute diverticulitis (AD) and signs of acute peritonitis, the presence of extradigestive air (EDA) on a computer tomography (CT) scan is often considered to indicate the need for emergency surgery. Although the traditional management of "perforated" AD is open sigmoidectomy, more recently, laparoscopic drainage/lavage (usually followed by delayed elective sigmoidectomy) has been reported. The aim of this retrospective study is to evaluate the results of nonoperative management of emergency patients presenting with AD and EDA. The outcomes of 39 consecutive hemodynamically stable patients (23 men, mean age = 54.7 years) who were admitted with AD and EDA and were managed nonoperatively (antibiotic and supportive treatment) at a tertiary-care university hospital between January 2001 and June 2010 were retrospectively collected and analyzed. These included morbidity (Clavien-Dindo) and treatment failure (need for emergency surgery or death). A univariate analysis of clinical, radiological, and laboratory criteria with respect to treatment failure was performed. Results of delayed elective laparoscopic sigmoidectomy were also analyzed. There was no mortality. Thirty-six of the 39 patients (92.3%) did not need surgery (7 patients required CT-guided abscess drainage). Mean hospital stay was 8.1 days. Duration of symptoms, previous antibiotic administration, severe sepsis, PCR level, WBC concentration, and the presence of abdominal collection were associated with treatment failure, whereas "distant" location of EDA and free abdominal fluid were not. Five patients had recurrence of AD and were treated medically. Seventeen patients (47.2%) underwent elective laparoscopic sigmoidectomy for which mean operative time was 246 min (range = 100-450) and the conversion rate was 11.8%. Mortality was nil and the morbidity rate was 41.2%. Mean postoperative stay was 7.1 days (range = 4-23). Nonoperative management is a viable option in most emergency patients presenting with AD and EDA, even in the presence of symptoms of peritonitis or altered laboratory tests. Delayed laparoscopic sigmoidectomy may be useless in certain cases and its results poorer than expected.

Septic Shock Secondary to a Pyogenic Liver Abscess Following Complicated Appendicitis.

Pyogenic liver abscesses (PLAs) are a rare condition in North America and Europe and, rarer still, the cause of septic shock. This case report will describe the rare occurrence of a PLA producing septic shock in a 36-year-old male residing in the United Kingdom following a case of complicated appendicitis. The patient presented to the emergency department (ED) with a three-week history of intermittent loose stools, cramping abdominal pain, recurrent fevers, a heart rate of 111 beats per minute, a blood pressure of 94/58 mmHg, and a fever of 40.1 degrees Celsius. Despite prompt broad spectrum antibiotic administration and three liters of fluid resuscitation, the patient remained shocked which led to an ICU admission. A CT scan prior to transfer found a 7 cm x 6 cm x 6 cm lesion representing a liver abscess (LA) as well as gross inflammatory change affecting the distal small bowel. The LA was managed through insertion of a percutaneous drain under ultrasound guidance performed by the interventional radiology team, as well as ongoing IV antibiotics. Following growth of the gut commensal <iStreptococcus constellatus</i from the abscess fluid culture, a colonoscopy was performed which found a severely distorted and inflamed terminal ileum with an impassable stricture, raising not only the suspicion of appendicitis but also Crohn's disease. Following the colonoscopy, after a total of 10 days admission, the patient was allowed to go home with a four-week course of oral co-amoxiclav. After discharge, the patient's case was discussed in the gastroenterology inflammatory bowel disease (IBD) multi-disciplinary team meeting due to concerns raised about possible Crohn's disease from the admission CT and following colonoscopy findings. Given the absence of relevant IBD symptoms, a reassuring outpatient MRI small bowel scan (found considerable resolution of the right iliac fossa inflammatory process) and a fecal calprotectin of 29 four months post discharge (normal=0-51 μg/g), it was concluded the terminal ileum changes were most likely accounted for by a complicated course of appendicitis. When reviewed in a telephone clinic 10 weeks post discharge, he was found to have no persistent gastrointestinal (GI) symptoms and was subsequently discharged. This case highlights the importance of comprehensive imaging and colonoscopy in the work up of those patients with PLAs with no otherwise evident precipitating factor.

[Emergency interventions in complicated colonic diverticulosis].

An account is given in this paper of 480 patients who had been hospitalised for colonic diverticulosis or diverticulitis in the surgical department of the Municipal Waid Hospital of Zurich, between 1970 and 1986. Laparotomy had to be performed on 219 of them (45.6 per cent), among them 84 emergency interventions. The average age of these patients was 70.7 years. Indications for emergency surgery included diffuse or locally delimited peritonitis with abscess development in 72 patients, ileus in ten cases, and massive colon haemorrhage in two. The latter two cases were handled with good success by subtotal colectomy with ileorectostomy and, one of them with the source of bleeding known, by colotomy and suturing of that source of bleeding. Sigmaincontinence resection according to Hartmann has been considered the optional approach since 1977 to diffuse peritonitis and to many cases of ileus (n = 39). In more recent time, anastomosis has been used as primary approach to some patients who survived fibrinous abdominal peritonitis (n = 4). The mortality rate associated with drainage operations according to expectation, has been clearly higher than that following resection, the comparable figures being 32.3 and 17.2 per cent. That has been attributable to non-removal of the septic focus. After all, nowadays combined antibiotic therapy is commonly used for seven to ten days for simultaneous control of both aerobic and anaerobic pathogens. This has become routine practice and involves aminoglycoside, metronidazole, and ampicillin. Overall mortality associated with emergency interventions is clearly higher than that after planned operations, the figures being 22.6 and 4.4 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic abdominal pain after laparoscopic hernia repair due to mesh graft migration to the cecum: a case report.

Hernia repair with mesh graft is one of the most common procedures in general surgery. Mesh graft repair is the treatment of choice for umbilical and periumbilical hernias to minimize recurrence. One of the rare but serious complications is mesh graft migration to viscus. These complications can occur months to years after repair and their diagnosis can be challenging as they may present as vague abdominal pain only. A 74-year-old gentleman with multiple medical comorbidities was diagnosed with a para-umbilical hernia after which he underwent a laparoscopic hernia repair at our hospital using a mesh graft with no complications. On postoperative day 10, he presented to the emergency room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea. A Computed Tomography (CT) scan of the abdomen and pelvis showed diffuse wall thickening of the cecum and terminal ileum with small free air worrisome for perforation. The decision was made in the ER to discharge him home on antibiotics. The patient then returned back multiple times to the ER for the same complaint along with bleeding per rectum for which he underwent further investigations. Months later, the patient presented again with the same symptoms. A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material. The patient was then taken to surgery and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints. It is important to consider mesh graft migration to viscus as a cause of persistent abdominal pain and bleeding per rectum irrespective of the time of presentation post hernia repair.

The Hartmann procedure. First choice or last resort in diverticular disease?

To critique changing trends in the surgical management of diverticular disease. Case series. Two hundred twenty-seven consecutive patients required surgery for diverticular disease from 1988 to 1993. Patient records were reviewed retrospectively. Operative procedures included primary resection in all patients with either anastomosis, anastomosis with proximal ileostomy, or the Hartmann procedure. Morbidity, mortality, and length of stay were then compared with each operative procedure and stage of disease. Patients were categorized according to the following pathologic stages: stage 0, no inflammation; stage I, chronic inflammation; stage II, acute inflammation with or without microabscesses; stage III, pericolonic or mesenteric abscess; stage IV, pelvic abscess; and stage V, purulent or feculent peritonitis. A university hospital and private affiliated hospitals in a large metropolitan area. Study outcome parameters included mortality, morbidity, length of hospital stay, and leak rates. These outcomes were then compared with different disease stages and treatments. Mean patient age was 66 years (range, 25-98 years). Male-female ratio was 84:143. Mean follow-up was 23 months (range, 1-132 months). There were 50 fistulas: 24 colovesical, 21 colovaginal, 3 colocolonic, 1 coloenteric, and 1 colouterine. Surgery was categorized as elective for 196 patients (86%), urgent for 12 (5%), and emergent for 19 (8%). Primary resection was performed in all cases. Primary anastomosis was performed in 200 patients (88%), 183 without and 17 with proximal diversion. Twenty-seven patients (12%) underwent a Hartmann procedure with colostomy; 19 patients (70%) have since undergone colostomy closure. Morbidity occurred in 52 patients (23%), including 4 anastomotic leaks (2%). There were 3 perioperative deaths (1%). Mean length of initial hospital stay was 11 days (range, 4-59 days). Length of stay was 5 days (range, 4-7 days) for ileostomy closure (7% morbidity) and 13 days (range, 7-35 days) for the colostomy closure after the Hartmann procedure (33% morbidity). Primary resection is virtually always possible in complicated diverticular disease. Primary anastomosis, with or without proximal diversion, is safe for patients with no abscesses or localized abscesses and should be considered on an individual basis for patients with pelvic abscesses and peritonitis. Colostomy closure after the Hartmann procedure is associated with significant length of hospitalization and morbidity and leaves one third of patients with permanent stomas.

Pyomyoma mimicking tubo-ovarian abscess: Two case reports.

Pyomyoma is an extremely rare complication, defined as an infection of a uterine leiomyoma. We describe two cases of pyomyoma that were initially considered to be tubo-ovarian abscesses but were later diagnosed as pyomyomas and managed with laparoscopic surgery. Case 1 was a 26-year-old nulliparous woman who was previously diagnosed with bilateral endometriomas and presented to the hospital with lower abdominal pain. Magnetic resonance imaging revealed bilateral endometrial cysts and a 4-cm mass consistent with a tubo-ovarian abscess. The patient experienced continuous pain, and the cyst in the left adnexa enlarged; thus, laparoscopic surgery was performed. The cystic tumor in her uterus contained purulent fluid. Therefore, an abscess in the degenerative subserous myoma was diagnosed. Case 2 was a 47-year-old nulliparous woman who had undergone total mastectomy and postoperative radiotherapy for breast cancer. She was undergoing hormone therapy when she presented to the hospital with lower abdominal pain, fever, and increased inflammatory markers. Computed tomography revealed a 7-cm tumor with rim enhancement in her left adnexa; therefore, a tubo-ovarian abscess was suspected. After admission, drainage was performed under transvaginal ultrasound guidance, and antibiotics were administered. However, these treatments did not relieve her abdominal pain. Emergency laparoscopic surgery was performed, and intraoperative findings demonstrated an abscess in the degenerative subserous myoma of the uterus with normal adnexa. Laparoscopic hysterectomy and bilateral salpingectomy were performed. Laparoscopic surgery was effective for both patients. Delayed diagnosis of pyomyoma can result in serious complications. Timely surgery with concomitant antibiotic treatment may facilitate good outcomes.

[Perforated diverticular disease of the left colon. Proposed single-stage left colectomy protected by a three-way lavage and active aspiration tube (di Gullino) positioned inside or below the anastomosis. Experience in 65 cases].

The incidence of perforative diverticulitis of the left colon is steadily increasing. Today the decision is generally taken to perform two-stage surgery: segmentary resection without (Hartmann's operation) or with anastomosis, but protected by a colostomy ("limited intervention"). This study aimed to examine standard colectomy performed in a single operation ("ideal intervention"). Left colectomy with primary ligature of the lower mesenteric artery and vein at the source and outlet, en bloc removal of the colon-mesocolon and immediate transverse colorectal anastomosis. Anastomosis protected by the omentum which is also used to peritonise the retroperitoneum and to wrap around the anastomosis, and anastomosis also protected by the author's three-way lavage and active aspiration tube in either a trans- or subanastomosis and transanal position. Urgency is essential for this single-stage operation, together with massive dose antibiotic treatment limited to the pre- and postoperative stages, but above all peritoneal cleansing using accurate, methodical, repeated and abundant lavage with 8-10-20 or more litres, but only used 500 ml at a time. Of these 65 cases, 40 (62%) were purulent localised peritonitis and 25 (38%) were generalised (14 purulent, 4 fecaloid and 7 fecal). 8 cases (12.3%) underwent surgery in three stages and 16 (24.6%) underwent sigmoidectomy in one or two stages ("limited intervention"), 41 cases (63%) (1985-95, when Gullino's three-way tube became available) underwent standard colectomy in a single stage. Morbidity in 10 cases/65 (15%) and septic mortality in 5 cases/65 (7.7%) (limited to generalised peritonitis alone) only affected patients undergoing "limited interventions", but none of the 41 patients undergoing "ideal intervention". Mortality was significantly influenced by age: 50% of over 80 year-olds, none below 60. Postoperative hospitalisation was 17.1 days (in the first stage) of "limited interventions" and 9.7 days for "ideal interventions". The results argue clearly in favour of the "courageous" ideal colectomy with peritoneal lavage and protection of the colorectal anastomosis using Gullino's three-way tube.

Psoas muscle abscess simulating acute appendicits: A case report.

Psoas abscess is a rare clinical entity with vague symptomatology. We report a psoas abscess that simulated symptoms of acute appendicitis. A twenty-five year old male presented pain irradiating to the right iliac fossa and lumbar region associated with thigh flexion. Laboratorial exams revealed leukocytosis with a neutrophil shift to the left. Abdominal Ultrasound showed significant intestinal distension and a small quantity of free fluid at the right iliac fossa. Laparotomy and an appendectomy were performed. During immediate post-operative, the patient evolved with worsening of the pain and the leukocytosis, therefore, we chose to maintain his antalgic posture. An abdominal Computerized Tomography scan with contrast was solicited, revealing an increase of the iliac and psoas muscles of the right side, and multiple bacterial focuses. A retroperitoneal access was performed and 300ml of purulent secretion was drained. Afterwards, we implanted a Penrose Drain. The patient had a good post-op evolution, being discharged 7days after the drainage. The psoas muscle is a flexor of the thigh. Psoas abscess is an underdiagnosed condition, its main treatment is surgery associated with antibiotic therapy. CT scan seems to be the best choice of diagnostic image exam, although some authors prefer the nuclear magnetic resonance. The psoas muscle abscess is uncommon and poorly characterized in its etiology, clinical associations, and its therapeutic approach. On the other hand, acute appendicitis is the most common abdominal emergency, with a 7% death rate, and surgery is its main treatment.

[Surgical treatment of acute diverticulitis. Our experience].

The treatment of the acute diverticulitis is still a stimulating and complex problem sustained by several anatomopathological and clinical factors and the possibility of different therapeutic options, being the operative mortality among 5% and 45%. With the modern technologies it is possible to follow the evolution of the illness so to perform more appropriate therapeutic plan. From 1997 to 2007 we have observed 278 patients with acute diverticulitis. In 219 (78,7%) patients the inflammatory and sub-occlusive condition has been faced with medical therapy, with resolution of the disease in 170 (61%) cases. In 49 (17,6%) patients we have gotten the resolution of the inflammatory disease, but not of the sub-occlusion and therefore we liked to submit them to surgical treatment in election. In 1 case we have found a colovesical fistula. A total of 59 (21,2%) patients with signs of acute abdomen have been submitted to surgery in urgency, within the 24 hours from the hospitalization. We have performed a primary resection with anastomosis and without stoma in all the patients, except in 3 cases in which we have done the Hartmann procedure for the cheap general conditions. We have not recorded intra and postoperative mortality and only in 3 cases we have had a leakage, that has not needed a surgical treatment. In 9 cases we observed infection of the wound, treated with antibiotic therapy. In our experience, performing a surgical procedure, without derivative stoma and manual anastomosis, it seems to be the fittest and less expensive procedure, also in situation of emergency-urgency, without increase of mortality and morbidity.

Intraperitoneal abscess after an undetected spilled stone.

Gallbladder perforation with loss of calculi in the abdomen is frequent during laparoscopic cholecystectomy and can cause serious late complications. We report on a 65-year-old woman who underwent laparoscopic cholecystectomy for gallbladder empyema, during which a stone spilled into the peritoneal cavity. The spilled gallstone was not noticed during the initial operation. Three months later, she reported left upper quadrant pain of recent onset without associated symptoms such as fever, nausea, or weight loss. On examination, a palpable 2-cm tender subcutaneous mass was found. Abdominal ultrasound demonstrated an incarcerated hernia, and computed tomography (CT) scan showed an intraperitoneal abscess located in the back of the anterior abdominal wall in the left upper quadrant, which contained a recalcification figure. The patient was brought to surgery, at which time an incision was made over the mass. A chronic abscess in the back of the abdominal wall, also spreading into the subfascial space, was drained, and purulent material was obtained with a large stone, 2.8 cm in diameter, which had become lodged in the rectus abdominis after an undetected stone spillage during laparoscopic cholecystectomy. The patient continued receiving antibiotic treatment for 7 days, recovered well, and was discharged 7 days after drainage of the abscess.

[The value of peroperative colonic lavage in urgent colonic surgery. Apropos of 54 patients].

The effects of on-table colonic irrigation followed by primary large bowel resection and anastomosis for emergency left colonic disease were prospectively studied in 54 patients. Eighteen patients had a diverticular sigmoiditis complicated by localized (8) or generalized (4) peritonitis, 6 presented a complete sigmoid obstruction. Thirty six patients had a left colonic occlusive (33) or perforated (3) cancer. Anterograde colonic irrigation was carried out with a mean volume of 7.7 l. All patients received a double or triple antibiotic combination. The anastomosis was handsewn in 33 cases and stapled (Knight-Griffen) in 21. Seven patients with severe peritonitis had a proximal transitory stoma which was closed within 4 months. Two patients (3.7%) died postoperatively, one for anastomotic dehiscence and the second for evisceration. We observed 7 cases of hypothermia (< 34 degrees C) during the irrigation. Six patients developed a sepsis of the surgical wound, 2 a septicemia and l an abscess in the right iliac fossa which was percutaneously drained. All complications had a favourable outcome. This study confirms that in selected cases a single stage surgery for colonic emergencies preceded by on-table irrigation grants good results and is a safe and effective alternative to Hartmann's procedure.

Sister Mary Joseph's nodule as a presenting sign of internal malignancy.

CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I.

Emergency laparoscopic surgery for complicated diverticular disease.

The aim of this study was to analyse the outcome of emergency laparoscopic surgical management of complicated diverticular disease. A prospectively collected electronic database of all colorectal laparoscopic procedures between April 2001 and September 2007 has been used to identify outcomes in patients presenting with complicated diverticular disease. Sixty-six patients (28 men), median age 69 years (23-95), ASA grade II (12), III (38), IV (16) have undergone emergency surgery for complicated diverticulitis--Hinchey grades I (27), II (29), III (7) and diverticular bleeding (3) over a 6(1/2)-year period: 43 high anterior resections, 17 Hartmann's resections and seven low anterior resections. Diverticular fistulas were seen in 16 patients: colovaginal (7), colovesical (2), colo-fallopian (4), entero-colic (3). The median operation time was 110 min (45-195 min). There was one conversion to open surgery. Postoperative analgesia was provided by intravenous Paracetamol in 33 patients (50%), patient-controlled analgesia in 24 (36%), oral Paracetamol and Oramorph (12%) and epidural opioid infusion (1.5%). The median time to normal diet was 24 h (4 h-6 days) and median hospital stay 5 days (2-30). There were two deaths (3.3%); anastomotic leak, ventricular fibrillation (VF) cardiac arrest. Other complications included: wound infection eight (12%), anastomotic leak four (8%), port-site hernia one and one case of Clostridium difficile colitis requiring colectomy. There were five (7.5%) returns to theatre and two readmissions (3%). Laparoscopic resectional surgery in complicated diverticular disease is a feasible, safe and a largely predictable operation that allows for early hospital discharge and, in our opinion, improved patient care. We are encouraged to continue to offer our patients the option of an emergency laparoscopic resection.

[Management of complications of sigmoid diverticulosis].

Computed tomography (CT) with contrast enhancement for vascular and bowel opacification is the reference examination for suspected sigmoid diverticulitis because it makes it possible to confirm the diagnosis and look for signs of severity (pericolic abscess, or presence of air or extraintestinal contrast product). Therapeutic management depends on the patient's general condition and on the severity of the intraperitoneal infection, assessed according to Hinchey's 4-stage classification. For Hinchey stages I and II (pericolic or pelvic abscess), radiologically guided puncture-drainage is an effective treatment, combined with antibiotic therapy. Emergency surgery is only indicated if this drainage fails. Two to three months later, elective prophylactic sigmoidectomy, by laparoscopy, is indicated. In stage III or IV diverticulitis (generalized purulent or fecal peritonitis), the surgical treatment of reference is a Hartmann procedure (sigmoidectomy and left iliac colostomy with closure of the rectal stump). But because of burden of the procedure and the risk of failing to re-establish gastrointestinal continuity, it is preferable, if local conditions allow, to propose resection-anastomosis with a temporary protective stoma. Prophylactic sigmoidectomy is controversial. It is indicated regardless of the number of episodes and regardless of age in patients at high risk of recurrence, that is, those with a complicated clinical form or radiologic signs of severity. There is no consensus for patients aged younger than 75 years with a first uncomplicated episode, for whom the risk of recurrence is also elevated. Finally, for patients older than 50 years with an uncomplicated episode on CT, the role of prophylactic surgery, even after 2 or 3 episodes, has not been demonstrated, because of the very low risk (<5%) of subsequent complications. More than 80% of diverticular hemorrhages stop spontaneously but their rate of recurrence is high (25% of cases) and they sometimes require emergency colectomy.

Hot Topics in Surgical Management of Acute Diverticulitiss.

In this session different issues for the surgical management of diverticular disease DD) were considered. The first session debated about the antibiotic treatment for acute uncomplicated diverticulitis (AUD), and supports their use selectively rather than routinely in patients with AUD. The second session discussed the best surgical treatment for those patients. Open approach is a valid choice especially in acute setting, while the laparoscopic approach should be individualised according to the level of skills of the surgeon and the risk factors of the patient (such as obesity and state of health at the time of the operation). The third session debated about the peritoneal lavage and drainage, which is still a safe surgical procedure. However, it requires longer follow-up and results of other trials to draw an adequate conclusion. The last session covers the current surgical certainties in managing complicated DD: 1. urgent colectomy has higher mortality in immune-compromised patients, while in elective surgery is comparable with other populations; 2. laparoscopic peritoneal lavage (LPL) should be the choice in young/fit patients; 3. elective resection is safer in an inflammation free interval; 4. laparoscopic resection shows advantages in several outcomes (such as post-operative morbidity and lower stoma and re-operation rate); 5. in Hinchey III/fecal peritonitis, primary sigmoid resection and anastomosis (open or laparoscopic) could be proposed in young/ fit patient; 6. in case of emergency surgery, Hartmann procedure (open or laparoscopic) must be considered in critically ill/unstable patient.

Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery.

Intra-abdominal abscesses are a frequent source of morbidity and mortality following both elective and emergent surgery of the alimentary tract. CT-guided percutaneous drainage of intra-abdominal abscess is an alternative to immediate surgical intervention. We studied the clinical characteristics and outcomes of patients undergoing percutaneous drainage of intra-abdominal abscesses arising after elective colorectal procedures. We retrospectively identified 40 patients with postoperative intraabdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage with a Von Sonnenberg sump drain between 1990 and 1998. The most common presenting symptoms were pyrexia in 39 (97%), abdominal tenderness in 32 (80%), guarding in 1 (2.5%) and abdominal mass in 3 (7.5%); no patient had generalized peritonitis. The most common index procedure was proctocolectomy with ileoanal anastomosis and ileal Jpouch in 12 (30%) patients. Drainage was performed using an anterior approach in 32 (80%) and a transgluteal window in 8 (20%) patients. Thirty-five (87.5%) patients had a single collection, while 2 (5.0%) patients had 2 collections and 3 (7.5%) patients had 3 collections. Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. Follow-up at a mean of 35.8 days revealed complete resolution of abscess in 26 (65%) patients; 14 (35%) patients had residual or recurrent abscess successfully treated by repeat drainage in 8 patients and requiring laparotomy in 6. Percutaneous CT-guided abscess drainage is an effective method for treating intra-abdominal abscess following elective colorectal surgery. The primary success was 65% after the first and 85% after a second drainage. In conclusion, this technique should be considered as the treatment of choice in patients with localized intra-abdominal abscess without signs of generalized peritonitis.

[Surgical tactics in complicated sigmoid diverticulitis].

Between January 1972 and February 1988 139 admissions (136 patients) for diverticulitis were registered. Treatment remained conservative in 47 cases. 23 cases underwent elective surgery. In 69 patients emergency-laparotomy had to be done. In 41 cases (3 deaths) the abdomen was washed out and drained, followed by a proximal colostomy. In 23 of these patients a free perforation had to be oversewn. 6 patients were treated by Hartmann resection (1 death). Primary resection, anastomosis and proximal colostomy were performed in 15 cases. 3 patients underwent exterritorization and resection. 4 patients with colonic ileus were initially treated by colostomy alone. There were 2 late deaths both from pulmonary embolism. Of the 63 patients who had a colostomy constructed 4 (6.3%) never had the stoma closed. There were 2 persistent stomas in the 41 patients who had a preliminary colostomy alone (4.9%) and the incidence of persistent stoma in 5 patients who had a Hartmann resection was 40% (2 cases). -The three-stage resection makes good results, provided that a free perforation is solidly oversewn to prevent further fecal contamination. Primary resection with anastomosis and proximal colostomy, which is more and more used in suitable cases, considerably shortens duration of treatment. Hartmann resection remains second choice because of the known high incidence of persistent stoma. It is submitted to surgeon's experience to choose at any situation the best procedure regarding age and general state, local findings and extent of peritonitis. With this tactic hospital lethality of emergency operation was 4 of 69 patients (5.8%), overall lethality 6 (8.7%). Intestinal continuity was restored in 94% of surviving patients.

[Two cases of curative resection by laparoscopic surgery following preoperative chemotherapy with bevacizumab for locally advanced colon cancer].

Here we report 2 cases of curative resection following preoperative chemotherapy with bevacizumab for locally advanced colon cancer. Case 1 was a 62-year-old man admitted with constipation, abdominal distention, and abdominal pain. An abdominal computed tomography(CT)scan revealed an obstructive tumor of the sigmoid colon with invasion into the bladder. A diverting colostomy was performed, and chemotherapy with mFOLFOX6(infusional 5-fluorouracil/Leucovorin+ oxaliplatin) plus bevacizumab was initiated. The tumor shrunk markedly after 6 courses of this treatment. Thereafter, laparoscopy- assisted sigmoidectomy was successfully performed. Case 2 was a 61-year-old woman admitted with diarrhea, abdominal pain, and fever. An abdominal CT scan revealed an obstructive tumor of the sigmoid colon with invasion into the ileum, uterus and retroperitoneum. A diverting colostomy was performed, and chemotherapy with XELOX(capecitabine+ oxaliplatin)plus bevacizumab was initiated. The tumor shrunk markedly after 6 courses of this treatment. Thereafter, laparoscopy- assisted sigmoidectomy was successfully performed. Both cases demonstrated partial clinical responses to chemotherapy; thus, curative resection surgeries were performed. There were no perioperative complications. Therefore, we conclude that oxaliplatin-based chemotherapy plus bevacizumab and laparoscopic resection could be very effective for locally advanced colon cancer.

Surgical options in acute diverticulitis: value of sigmoid resection in dealing with the septic focus.

The outcome of 78 patients hospitalized with acute diverticulitis was analysed to determine the indications for emergency operation and to examine the safety of sigmoid resection. Forty patients improved on medical therapy, but four relapsed soon after discharge. Forty-two (55%) patients had emergency operations for non-resolution of clinical sepsis (25), persistent symptoms or mass (14) and fistula (three). Operations performed were: sigmoid resection and primary anastomosis (23) with covering colostomy (six). Hartmann's operation (10), drainage with/without colostomy (seven) and right hemicolectomy (two). Findings at operation were: abscess (19), phlegmon (14), generalized peritonitis (six), colovesical fistula (three) and chronic diverticulitis (three). Complications included wound infections (six), respiratory complications (five) and one death. Six patients having drainage of the sigmoid inflammation alone as the first operation required subsequent resection, with prolonged and often complicated hospitalization. Minimal morbidity and shorter hospitalization were achieved when sigmoid resection was performed at the initial procedure.

Pancreatic Leak After a Laparoscopic Sleeve Gastrectomy.

Severe adhesions in patients with previous abdominal operations may lead to a more challenging subsequent bariatric surgery [1, 2]. In this context, sleeve gastrectomy (SG) is the preferred weight loss surgery since it solely involves stomach resection (without bowel involvement) in one abdominal compartment. Additionally, SG has lower complication rates and a shorter operative time than other bariatric procedures [3, 4]. In this paper, we present a multimedia video of the management of a pancreatic leak after SG in a patient with multiple previous abdominal surgeries. A 40-year-old female with a BMI of 36 kg/m<sup2</sup and obesity-related comorbidities presented to our clinic for bariatric surgery evaluation. The patient had a history of a motor vehicle accident requiring a splenectomy, a liver laceration requiring packing and reoperation with an open abdomen for more than a month. This was followed by a hernia repair with component separation. Preoperative workup was completed, including an upper endoscopy (EGD) that was negative for esophagitis. The computed tomography (CT) scan showed an area in the left upper quadrant with no bowel loops adherent to the abdominal wall, thus a safer area for accessing the abdominal cavity (Fig. 1). The SG itself was challenging due to severe adhesions. These adhesions were between the bowel and abdominal wall, bowel and bowel, stomach and liver, and posterior stomach and pancreas (video). Once adhesiolysis was completed, the stomach was tailored successfully without intraoperative complications. The patient was discharged on postoperative day 1 with stable vitals and laboratory exams while tolerating a liquid diet. On postoperative day 2, the patient returned to the emergency department with abdominal pain, increased heart rate (120 per minute), and a white blood cell count (WBC) of 20,000 th/µL. The CT scan showed a left upper quadrant collection with no evidence of air or contrast extravasation from the sleeve, as shown in Fig. 2. The patient became unstable and did not respond adequately to resuscitation efforts. Due to the extensive dissection in the primary operation, we elected to perform a laparoscopic exploration on an urgent basis. A collection (dark fluid) was noted in the left upper quadrant, but no sleeve staple line leak was found even with the air leak test (Fig. 2). Drainage and wash out were completed, and 2 abdominal drains were placed. Although the patient had symptomatic improvement postoperatively, an EGD with fluoroscopy was repeated, and no leak was noted (Fig. 3). The fluid evaluation showed increased lipase suggesting the diagnosis of a pancreatic leak. A liquid diet was initiated, and the initial drain in the left upper quadrant was exchanged to a higher caliber one (16F 40 cm locking loop drain). The patient was stable and eventually discharged home on postoperative day 6. Eventually, the drains were draining less than 10 mL and then downsized and removed. The patient's weight loss journey continued afterward with no other complications at 10-month follow-up. Pancreatic leak is a rare but potentially severe complication after SG, especially in the difficult abdomen.

Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis.

The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management. A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013). Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making. The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients.

Hybrid transvaginal natural orifice transluminal endoscopic surgery of radical sigmoidectomy for sigmoid colon cancer.

Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique - "scarless" abdominal operations performed with a multi-channel endoscope passed through a natural orifice (mouth, urethra, anus, vagina etc.) and offers less invasive and more excellent cosmetic results [1]. It is regarded as safe and feasible in patients with benign disease [2,3]. The first case of pure NOTES for sigmoid colon cancer was reported in 2012 [4]. We describe here a case of curatively intended resection for early-stage sigmoid colon cancer using the hybrid transvaginal NOTES approach. This video demonstrates the case of a 52-year-old woman with sigmoid colon cancer treated by hybrid transvaginal NOTES. Her body mass index was 20.4 kg/m<sup2</sup. A laparoscope was inserted above the umbilicus and tumor's position was located. Two 5 mm trocars inserted in the right lower abdominal quadrant were mainly used for the assistant's instruments to provide traction and exposure. A single-port was inserted into the abdominal cavity transvaginally through the colpotomy. Then all the procedures were performed transvaginally with conventional rigid laparoscopic instruments. The sigmoid colon was mobilized using a lateral to medial approach. Then the root of the inferior mesenteric artery and the inferior mesenteric vein were divided with absorbable clips. After complete isolation of the proximal rectum, the rectum was transected 5 cm distal to the lesion with a linear stapler inserted through the single port. The proximal resection margin of descending colon was identified and the transection of the colon was performed. The specimen was removed transvaginally. The colon was then exteriorized and the anvil was fixed in the colon. An end-to-end anastomosis was performed using a circular stapler, and a leak test was done. The operative time and estimated blood loss were 182 min and 50 mL. A 20 cm long segment of sigmoid colon was resected with negative tumor margins, and 16 lymph nodes were harvested. There was no intraoperative or postoperative morbidity. The patient was with out-of-bed activity on day 1, fluid diet on day 2, bowel movement on day3, and the drainage tube and catheter removing on day 4. On day 5, she was discharged. Pathological examination revealed a moderately-differentiated adenocarcinoma: 50 × 45 × 10 mm, with growing into subserosa, without vascular or nervous invasion, pT3N0M0 and pStage IIA. There were two scars less than 5 mm and one scar less than 10 mm visible on the abdominal wall at one month. The patient was alive without recurrence after one year's follow-up. Hybrid transvaginal NOTES of radical sigmoidectomy may be safe and feasible for selected patients with sigmoid colon cancer and give less pain, potentially low rates of complication, faster recovery, and better cosmesis. A future large study is warranted to better evaluate this procedure. Although there are many reasons for skepticism, there is undoubted interest in this field from both surgeon and patient.

Outpatient treatment in uncomplicated acute diverticulitis: 5-year experience.

Most cases of diverticular inflammation are mild and require only medical treatment with liquid diet and antibiotics. Until recently, this treatment required admission to hospitals, which consequently entailed costs. In most cases, treatment was conservative, and less than a quarter of patients admitted actually underwent surgery. In the last year, the outpatient treatment of these patients with uncomplicated diverticulitis has proven effective and safe. The aim of the present study was to describe our experience after 5 years of outpatient treatment with oral antibiotics. We conducted a retrospective revision study between January 2010 and December 2014. We included all patients admitted to the Emergency Department of the University General Hospital of Elche with a diagnosis of uncomplicated acute diverticulitis based on medical history, physical examination and abdominopelvic computed tomography (CT) scanning. Outpatient treatment consisted of oral antibiotics for 10 days (metronidazole 500 mg/8 h and ciprofloxacin 500 mg/12 h), a liquid diet and oral analgesics (acetaminophen 1 g/6 h). During the period from January 2010 to December 2014, 224 patients were treated on an outpatient basis at a success rate of over 92%. Only 18 patients (8%) required admission after outpatient treatment. Outpatient treatment of uncomplicated acute diverticulitis was demonstrated to be safe and effective.

Crohn's Disease Complicated With Extensive Thrombosis of Limbs and Mesenteric Arteries: A Case Report and Literature Review.

Crohn's disease (CD) is a lifelong disease characterized by purulent inflammation in the gastrointestinal tract from any part of the mouth to the anus. Various studies have reported complications of the CD. However, arterial thrombosis is an extremely rare complication of CD. We report a patient with CD with extensive thrombosis of the extremities and mesenteric arteries. A 41-year-old man came to our hospital for 2 months of discomfort in the right upper abdomen and had previous left lower extremity arterial occlusive disease and left upper limb ischemic contraction for more than 2 months. The patient developed fever and abdominal pain repeatedly after admission; because of the increased abdominal pain, we urgently performed a laparotomy for him. And according to the findings in the surgery, we decided to perform partial small intestine resection, cholecystectomy, common bile duct exploration, and T-tube drainage. Pathological findings of postoperative specimens showed Crohn's disease and mesenteric atherosclerosis with mesenteric artery thrombosis. We performed a series of treatments such as 5-aminosalicylic acid, intravenous infusion, broad-spectrum antibiotic infection treatment, nutritional support, and low molecular weight heparin. The patient was successfully discharged from the hospital. The occurrence of IBD with arterial thromboembolism is extremely rare but can lead to serious consequences. During IBD treatment, we should be aware of the possibility of TEs (especially arterial TEs) and should be alert to the possibility of arterial TEs in young patients with IBD with active and extensive disease.

Urgent surgery for sigmoid diverticulitis. Retrospective study of 118 patients.

Aim of our study was to identij5 the risk factors for operative morbility and mortality after urgent surgery for complicated sigmoid diverticulitis. A further end point was define the adequate surgical approach in these patients. Data fJom 118 patients who were admitted for emergency surgery between 2000 and 2009 for non-haemorrhagic complicated diverticulitis of the sigmoid colon were retrospectively evaluated and analysed. Operative options included resection with primary anastomoses (PA), Hartmann's procedure (HP) and colostomy. All operative complications were noted and potential risk factors listed. One hundred eighteen patients were enrolled in this study. Surgery for peritonitis was indicated for 102 patients and for intestinal obstruction in the remainder. Overall morbidity and mortality rates were 37.3% and 9.3%, respectively. Primary resection was performed on 113 patients (95.8%). Age greater than 70 years, diffuse peritonitis, Mannheim Peritonitis Index (MPI) above 18, and symptoms lasting longer than 24 hours are considered as independent risk factors for operative morbidity and mortality. Our results confirmed that while age older than 70 years and delaying treatment (>24h) are independent risk factors for operative morbidity and mortality, comorbidity is not. According to general guidelines, first target of surgery was to attempt a primary resection of the diseased colon (95.8% of our patients). In our series an high rate of Hartmann procedure (HP) in Hinchey's class 2 patients was observed. This unusually high number is explained by the rate (68.4%) of pelviperitonitis diagnosed in these patients. Extended pelvic peritonitis is generally defined as a local peritonitis (class 2 Hinchey), which is not accurate. Colonic resection in these cases would not completely remove peritoneal contamination and renders the indication for PA questionable. Emergency surgery for complicated diverticulitis is characterised by high rates of morbidity and mortality. Age greater than 70 years, symptoms lasting longer than 24 hours, MPI above 18, and diffuse peritonitis were significant predictors. Early eradication of septic focus is the main goal of surgery. Primary anastomosis is recommended only if sepsis is completely removed.

Post-colostomy internal hernia of the stomach treated with laparoscopic gastropexy: a case report.

Internal hernias are formed by the protrusion of internal organs through an aperture formed congenitally or postoperatively. Internal hernias are most commonly associated with the small intestine. Only two cases of a post-sigmoid colostomy internal hernia of the stomach have been reported. This hernia arises from the space between the lifted sigmoid colon and the left abdominal wall. In the two aforementioned cases, treatment comprised suturing of the sigmoid colon to the lateral abdominal wall and changing of the intraperitoneal route to an extraperitoneal one. Herein, we present a very rare case who underwent laparoscopic gastropexy for a post-sigmoid colostomy internal hernia of the stomach. Our patient, a 67-year-old woman, was undergoing chemoradiation for rectal cancer and planned to undergo abdominoperineal resection. However, tumor perforation resulted in a high fever and a right gluteal abscess; therefore, a sigmoid colostomy was performed through the intraperitoneal route in the left lower abdomen. One month after the surgery, the patient presented to our emergency room with vomiting, abdominal pain, and abdominal distension. Computed tomography revealed a markedly distended stomach caused by the obstruction of the pylorus secondary to the colostomy; laparoscopic gastropexy was performed subsequently and the postoperative course was uneventful. This is the first report on the laparoscopic gastropexy treatment of a post-sigmoid colostomy internal hernia of the stomach; our findings may help physicians manage such hernias.

Surgery for Crohn's disease in Greece: a follow-up study of 79 cases.

The aim of this prospective study was to elucidate the clinical features, indications for surgery and long-term outcome of a series of 79 Greek patients operated on for Crohn's disease. The clinical features and follow-up of 79 out of 155 patients with definite diagnosis of Crohn's disease (51%), who were operated on at least once during the course of their disease, are analyzed. Three main locations of the disease were identified (small bowel, large bowel and small and large bowel). The need for surgery, indications for surgery and outcome of patients were analyzed and compared separately for these three main locations. The mean follow-up period after the first operation was 8.8 +/- 6.5 years. The proportion of men to women was 1.55:1 (P = 0.068). The main indication for surgery was poor response to conservative treatment, followed by obstructive ileus, erroneous diagnosis of acute appendicitis and development of fistulae or abscesses. Statistically significant differences between the three main locations of the disease were found for obstructive ileus (P < 0.01), and bowel perforation (P < 0.0297). Enterectomy and end-to-end anastomosis was the most frequently performed operation. Minor surgical procedures were performed mainly for drainage of perianal abscess. Differences in the number of operations required (one, two and three or more) according to the three main locations of the disease were statistically significant (P < 0.044). Emergency operation was required in 17.3%. Most of the urgently operated patients had only small bowel involvement. Twenty-six percent of patients required a surgical procedure for perianal disease. One or more, major or minor, perioperative complications occurred in 13 out of 79 operated patients (16.4%). No perioperative deaths were noticed. Evolution to cancer was observed in 2% (3 patients). The outcome of patients after the operation was characterized by exacerbations and remissions. A mortality rate of 11.6% was noticed in the follow-up period. However, most deaths were unrelated to the underlying Crohn's disease. The clinicoepidemiological characteristics of patients with Crohn's disease of Greek origin operated-on for their disease do not differ significantly from those reported from other Western or neighboring Mediterranean countries. However, other parameters such as the relatively low incidence of overall surgical need, the low incidence of colorectal cancer and the low incidence of surgery for perianal disease, all underline the importance of various genetic and environmental factors on the evolution and behavior of the disease in different parts of the world.

Sterile abdominal abscess resulting from remnant laparoscopic clips after sigmoidectomy: a case report and literature review.

The occurrence of intra-abdominal sterile abscesses due to remnant clips after laparoscopic sigmoidectomy is rare. Here, we report one such case in a 74-year-old woman. Two years after laparoscopic sigmoidectomy, abdominal CT indicated an area of fluid accumulation approximately 5 cm in diameter and located in the middle of the abdominal cavity that contained a cluster of clips. Fine-needle aspiration of the fluid was performed through the wall of the sigmoid colon. The luminal fluid was found not to contain cancer cells on histological examination. After 1 year, abdominal surgery was performed. The abscess was located in the mesorectum at the anastomosis site; it was incised and a significant quantity of ivory-white viscous solution containing a cluster of clips was extracted. This case emphasizes the importance of reducing the number of clips used in laparoscopic surgery.

[Summary of the practice guideline on diverticulitis in the colon: diagnostics and treatment in specialty care].

The natural course of diverticulitis is usually mild and often requires only conservative treatment. The combination of pain in the lower left abdomen on physical examination, the absence of vomiting and a CRP > 50 mg/l is highly predictive of diverticulitis; further investigation by means of imaging may then be omitted. An initial ultrasound - and CT scanning only if this investigation proves negative or inconclusive - provides the best results in terms of imaging. There is no evidence substantiating the efficacy of routine antibiotic administration to patients with clinically mild and uncomplicated diverticulitis. Pericolic or pelvic abscesses can initially be treated with antibiotics, possibly in combination with percutaneous drainage; surgical intervention is only necessary if this treatment regimen fails. A patient with perforated diverticulitis resulting in peritonitis should undergo an operation; the optimal surgical strategy is currently under debate.

Laparoscopic Double Discoid Resection With a Circular Stapler for Bowel Endometriosis.

To demonstrate the technique of laparoscopic double discoid resection with a circular stapler for bowel endometriosis. Case report (Canadian Task Force classification III). Private hospital in Curitiba, Paraná, Brazil. A 33-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 6-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the submucosa, 5 cm far from the anal verge. Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veres needle placed at the umbilicus. Four trocars were placed: a 10-mm trocar at the umbilicus for the zero-degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions, and all implants in the anterior compartment of the pelvis were resected. The lesions located at the ovarian fossae were completely removed. The ureters were identified bilaterally, and both para-rectal fossae were dissected. The right hypogastric nerve was released from the disease laterally. The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum. The lesion was shaved off the anterior rectal wall using a harmonic scalpel. A x-shaped stitch was placed at the anterior rectal wall using 2-0 mononylon suture. A 33-mm circular stapler was placed transanally under laparoscopic control, and once it reached the area to be resected, it was opened. A gap was created between the envil and the stapler. The anterior rectal wall was placed inside this gap with the aid of the stitch at the anterior rectal wall. The stapler was fired, and a piece of the anterior rectal wall was resected. The same procedure was performed using a 29-mm circular stapler, which allowed for the complete removal of the lesion. We usually perform the second discoid resection using a 29-mm circular stapler to allow an easy progression of the stapler through the rectum beyond the first stapler line, so not to put too much pressure on it. In our experience, the first discoid resection removes most of the disease, and the second discoid resection is only needed to remove a small amount of residual disease, along with the first staple line. The procedure took 177 min, and the estimated blood loss was 100 mL. The patient started clear liquids 6 hours after the procedure, and was discharged 19 hours after that [1]. Pathological examination of the 2 strips of the anterior rectal wall revealed infiltration of the bowel wall by endometriotic tissue. She had an uneventful postoperative course, and was able to re-start sexual intercourse 50 days after surgery. Between January 2010 and January 2015, 315 women underwent laparoscopic surgery for the treatment of bowel endometriosis in our service. Among them, 16 (5.1%) were operated on by using the double discoid resection technique. Median age of the patients was 34 years, and median body mass index was 25.9 kg/m(2). Median preoperative cancer antigen-125 level was 26.5 U/mL (normal value is <35 U/mL). Median size of the rectosigmoid nodule was 35 mm (range: 30-60), and median distance from the anal verge was 10.5 cm (range: 5-15 cm). Median surgical time was 160 min (range: 54-210 min). Concomitant procedures included hysterectyomy (n = 5), partial cystectomy (n = 3), resection of the posterior vaginal fornix (n = 4), and appendectomy (n = 1). Median estimated intraoperative bleeding was 32.5 mL (range: 30-100), and median time of hospitalization was 19 hours (range: 10-41). Median American Fertility Society score was 46 (10-102). Two minor complications (12.5%) occurred in this initial series: 1 patient required bladder catheterization for urinary retention; and 1 patient developed a urinary tract infection that required oral antibiotic treatment. One major complication (6.2%) was observed; the patient developed fever and abdominal pain on the fourth postoperative day. She was re-operated, and the intraoperative diagnosis was pelviperitonitis. The abdominal cavity was inspected for any dehiscence of the bowel and then washed. She was discharged on the second day after re-operation with oral antibiotic therapy. In our daily practice, we are used to discharging our patients soon in the postoperative setting (19 hours for rectal shaving or discoid resection and 28 hours for segmental bowel resection) [1] because the rate of postoperative fistula seems to be low [2]. Because we still have not seen any fistulas after conservative surgery (rectal shaving, discoid resection, and double discoid resection), we usually prefer to perform this type of surgery compared with segmental bowel resection, when possible. Laparoscopic double discoid resection with circular stapler may be an alternative to segmental bowel resection in selected patients with bowel endometriosis.