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Abstract Background In patients who undergo low anterior rectal resection, the fashioning of a covering stoma (CS) is still controversial. In fact, a covering stoma (ileostomy or colostomy) is worsened by major complications related to the procedure, longer recovery time, necessity of a re-intervention under general anesthesia for stoma closure and poorer quality of life. The advantage of Ghost Ileostomy (GI) is that an ileostomy can be performed only when there is clinical evidence of anastomotic leakage, without performing further interventions with related complications when anastomotic leak is absent and therefore the procedure is not necessary. Moreover, in case of anastomotic dehiscence and necessity of delayed stoma opening, mortality and morbidity in patients with GI are comparable with the ones that occur in patients which had a classic covering stoma. On the other hand, is simple to think about the possible economic saving: avoiding an admission for performing the closure of the ileostomy, with all the costs connected (OR, hospitalization, post-operative period, treatment of possible complications) represents a huge saving for the hospital management and also raise the quality of life of the patients. Methods In this study we prospectively analyzed 20 patients who underwent anterior extra-peritoneal rectum resection for rectal carcinoma with TME and fashioning of GI realized with or without abdominal parietal split. Results In the group of patients that received a GI without split laparotomy mortality was absent and in one case an anastomotic leak occurred. In the group of patients in which GI with split laparotomy was fashioned, one death occurred and there were one case of infection and one respiratory complication. Clinical follow-up was 12 months. Conclusions The use of different techniques for fashioning a GI do not present significant differences when they are performed by expert surgeons, but further evidence is needed with more randomized trials, in order to have more data supporting the clinical observation.

Abstract Background In western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types. Methods We realized a retrospective clinical study including all the patients treated for sigmoid volvulus in the Department of General Surgery, St Maria Hospital, Terni, from January 1996 till January 2009. We selected 23 patients and divided them in 2 groups on the basis of the clinical onset: patients with clear clinical signs of obstruction and patients with subocclusive symptoms. We focused on 30-day postoperative mortality in relation to the surgical timing and procedure performed for each group. Results In the obstruction group mortality rate was 44% and it concerned only the patients who had clinical signs and symptoms of peritonitis and that were treated with a sigmoid resection (57%). Conversely none of the patients treated with intestinal derotation and colopexy died. In the subocclusive group mortality was 35% and it increased up to 50% in those patients with a late diagnosis who underwent a sigmoid resection. Conclusions The mortality of patients affected by sigmoid volvulus is related to the disease stage, prompt surgical timing, functional status of the patient and his collaboration with the clinicians in the pre-operative decision making process. Mortality is higher in both obstructed patients with generalized peritonitis and patients affected by subocclusion with late diagnosis and surgical treatment; in both scenarios a Hartmann's procedure is the proper operation to be considered.

Abstract Background Cholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage. Methods We report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage. Conclusion The management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, it's most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.

Introduction: Intestinal obstruction by congenital internal hernia is rare and unsuspected. Case report: We report the case of a 45 years-old-man diagnosed to have an intestinal obstruction caused by a double concomitant internal hernia. CT scan can provide a fast diagnosis in order not to delay the surgical intervention: the ileum had been entrapped into a big internal hernia between the transverse and the descending colon and the patient was diagnosed to have a paraduodenal hernia. During the intervention a concomitant mesosigmoid defect was found. Results: Our patient had a left paraduodenal hernia with much of the small bowel crowned into a round peritoneal membrane just in front and left to the duodenum and pancreas and between the transverse and descending colon. CT scan showed encapsulated cluster of small bowel loops in the hernia sac. He was taken up for surgery and an urgent laparoscopic access was performed for definitive diagnosis and treatment 4 days after the beginning of the symptoms. Conclusions: Congenital Internal Hernia should be considered as a cause of bowel obstruction in absence of previous abdominal surgery and, even if preoperative diagnosis of a paraduodenal hernia is difficult, it must be considered as part of differential diagnosis. [ABSTRACT FROM AUTHOR]

Background: Diverticular disease of the colon is common in the Western world. With the first episode of diverticulitis, most patients will benefit from medical therapy, but in 10% to 20% of cases some complications will develop, such as intra-abdominal abscesses, obstructions, fistulas. In these conditions it is important to define the most appropriate surgical approach. Discussion: The management of diverticular disease has been successful owing to the advances in diagnostic methods, intensive care and surgical experience, but there is debate about the best treatment for some conditions. Fistulas complicating diverticulitis are the result of a localized perforation into adjacent viscera. In particular, the connection between the colon and the urinary tract is a serious anatomical abnormality that must be urgently corrected before a serious urinary infection results. Indications, timing and surgical procedures are determined by the severity of the disease and the patient's general condition. Summary: Diverticular disease can lead to many complications. One of the most difficult to correct is an internal fistula, such as a colo-vesical fistula. The correct approach in cases where the disorder is clinically suspected has always been controversial, and the guidelines for sigmoid diverticulitis have not established the most appropriate method for diagnosis and treatment. At present, the surgical strategy for these cases requires interruption of the fistula and resection to remove the inflamed colonic segment, with or without primary anastomosis, focusing attention on the construction of the anastomosis to well vascularized and anatomically healthy tissues. It is clear, therefore, that establishing guidelines is difficult, because many pathological situations may be related to diverticulitis, and so, as our experience shows, the surgical approach has to be tailored to the patient's general and local condition. [ABSTRACT FROM AUTHOR]

Malignant melanoma is the neoplasm with highest probability of cardiac metastatization. Cardiac involvement by metastatic melanoma is rarely identified ante-mortem (5-30% of cases) for non-specificity of cardiac symptoms. In fact we show in this case report that abdominal pain can represent the predominant symptom. Furthermore we show the importance of linkage between clinical & anamnestic data which if underestimated can lead to an improper management and to the patient exitus.