Advantages of Damage Control Strategy With Abdominal Negative Pressure and Instillation in Patients With Diffuse Peritonitis From Perforated Diverticular Disease

Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients' conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann's procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann's procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.

[Our experience in the management of patients with Mirizzi syndrome]

The authors report their experience in the management of patients with Mirizzi Syndrome (MS) admitted, over a period of 15 years, at the General Surgery of Emergency Department of Cardarelli Hospital, Naples, Italy. All patients were admitted and surgically treated in emergency save for one. Out of 12 patients, cholecystectomy was performed in 7 cases. In others 5 patients, with cholecystocholedochal fistula, cholecystectomy with positionig of T-Tube was performed in 4 cases (MS-II); finally, 1 patient with MS type III undewrwent choledochojejunostomy. According to literature, the diagnostic protocol included abdominal ultrasonography and CT scan of the abdomen for all patients; in one case, a cholangio-MRI was performed to clarify the diagnosis. The preoperative diagnosis is essential to reduce risk of iatrogenic injuries. The cholangio-MRI, used to this extent, clarifies the site of obstruction, shows the anatomy of the biliary tree and allows to make all the possible differential diagnoses in order to exclude the presence of biliary tumors before surgery. The intraoperative cholangiography remains mandatory to clarify the anatomy of the biliary tree. In the cases we have treated, ERCP was never performed. We believe that ERCP has limited indications and unsatisfactory outcomes for both diagnosis and treatment of MS. Pathological examination of the fresh-frozen surgical specimens was always performed intraoperatively to exclude the presence of concomitant cancer of the gallbladder. The traditional treatment of patients with MS is surgery, as confirmed by our experience. We perform cholecystectomy for MS type I and cholecystectomy with direct repair of the biliary fistula over aT tube for MS type II. Patients with MS type III usually undergo a tailored operation based on the intraoperative findings, while choledochojejunostomy is mandatory for patients with MS type IV. Laparoscopic surgery is indicated only for MS type I and II. It seems to carry a higher risk for the patient and we do not use this approach in the emergency settings.

[Mainly abdominal "complex" polytrauma. Considerations on surgical strategy and clinical case report]

The Authors want to present un uncommon case of polytrauma managed with surgical treatment at the Trauma Center of the A. Cardarelli Hospital in Naples. Chest, abdomen, pelvis, and left lower limb have been severely injured. This case is so interesting because of the rareness of some lesions (i.e. diaphragm rupture) and the numerous lesions of internal organs (i.e. lungs, spleen, liver, pancreas, mesenterium) and of the bones (i.e. thigh-bone and pelvis). A very good outcome has been obtained for survival as well as for functionality and quality of life since we have strictly applied the rules for the management of the "complex" polytrauma.

[Conservative treatment of the digestive fistulas: personal experience]

OBJECTIVE

The authors, thanks to experience obtained in an Unit for the treatment of digestive fistulas, discuss the possibility of a conservative treatment for the anastomotic fistulas.

MATERIAL AND METHODS

From 2000 to 2003 were treated thirty-five patients with post-anastomotic gastroenteric fistulas marked according to their localization, way end output (51.5% high, 42.8% moderate and 5.7% low). The treatment is based on an aspiration system, sometimes integrated with an irrigation system. A semi-permeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic, polymer covered with a self-adherent surgical sheet. This system create a vacuum chamber equipped with a subathmospheric pressures between 262.2 and 337.5 mmHg (350-450 mmbar), integrated with a continuous irrigation using antibiotic solutions or 3% lactic acid.

RESULTS

The AA. obtained the resolution in 30 patients (85.7%), 3 patients needs the surgery (8.6%), 2 died, one for sepsis and the other one for malnutrition. The mean time for the closure was 45 days (from 20 to 90). A part of digestive external fistulas goes to spontaneous resolution so comes the idea that the creation of particular condition is the basis of their closure.

[The congenital cystic dilatation of the liver and bile ducts (CDB): our experience]

The congenital cystic dilatation of the liver and bile ducts (CDB) is a very uncommon disease. It often appears in females and most frequently in paediatric patients. Its etiopathogenesis is not yet completely defined. Its evolution includes, together with several complications, the malignant transformation. The Authors present the outcomes of their experience based on a series of 5 patients observed from 1991 till today. Apart from the rarity of this disease, their series is so interesting because 4 out of 5 are adult patients and the fifth one is over 15. In addition, differentiating from the literature trend, the group included only male patients. Are also discussed the most important aspects referring to nosology, epidemiology, etiopathogenesis, clinical pattern and its evolution of CDB, looking over a wide review too. The Authors extensively examine the diagnostic problems; owing to that the patients were observed in the period 1991-1999 it is necessary to clarify that some imaging methods, i.e. CSTscan and the bile duct MNR, were not yet introduced. The surgical treatment has been investigated as well, developed during its historical evolution until nowadays and our solutions for the 5 cases have been presented and discussed. In their series the Authors haven't ever observed during hospitalisation a malignant transformation.

[Aneurysm of the hepatic artery. A case report]

The authors describe the case of the sixty-one-year-old man admitted to hospital because of a growing jaundice that after the surgical operation proved to be caused by a compression of the PBV determined by a voluminous aneurysm of the hepatic artery. The integrity of the gastroduodenal artery made it possible to make a simple aneurysmectomy with clinic. The patient was discharged from hospital after fifteen days from the surgical operation; he was surgically healed and with normal enzymatic values. The follow-up two years after discharge confirmed a hematochemical state within normal limits.