Perforated duodenal diverticulum: Surgical treatment and literature review

INTRODUCTION

Duodenum is the second most frequent location for a diverticulum in the digestive tract. Complications are rare and perforation was only reported in less than 200 cases.

PRESENTATION OF CASE

A 79-year-old female was admitted to Emergency Department with abdominal pain and vomiting for the last 24 h. A CT scan was performed and moderated extra-luminal air was identified. During surgery a fourth portion perforated duodenal diverticulum was diagnosed and duodenal resection was performed.

DISCUSSION

First reported in 1710, the incidence of duodenal diverticula can be as high as 22%. Nevertheless complications are extremely rare and include haemorrhage, inflammation, compression of surrounding organs, neoplastic progression, cholestasis and perforation.As perforations are often retroperitoneal, symptoms are nonspecific and rarely include peritoneal irritation, making clinical diagnose a challenge.CT scan will usually present extra-luminal retroperitoneal air and mesenteric fat stranding, providing clues for the diagnosis.Although non-operative treatment has been reported in selected patients, standard treatment is surgery and alternatives are diverse including diverticulectomy or duodenopancreatectomy.

CONCLUSION

Perforated diverticula of the fourth portion of the duodenum are extremely rare and current evidence still supports surgery as the primary treatment modality.     

Role of preoperative carbohydrate loading: a systematic review

INTRODUCTION

Surgical stress in the presence of fasting worsens the catabolic state, causes insulin resistance and may delay recovery. Carbohydrate rich drinks given preoperatively may ameliorate these deleterious effects. A systematic review was undertaken to analyse the effect of preoperative carbohydrate loading on insulin resistance, gastric emptying, gastric acidity, patient wellbeing, immunity and nutrition following surgery.

METHODS

All studies identified through PubMed until September 2011 were included. References were cross-checked to ensure capture of cited pertinent articles.

RESULTS

Overall, 17 randomised controlled trials with a total of 1,445 patients who met the inclusion criteria were identified. Preoperative carbohydrate drinks significantly improved insulin resistance and indices of patient comfort following surgery, especially hunger, thirst, malaise, anxiety and nausea. No definite conclusions could be made regarding preservation of muscle mass. Following ingestion of carbohydrate drinks, no adverse events such as apparent or proven aspiration during or after surgery were reported.

CONCLUSIONS

Administration of oral carbohydrate drinks before surgery is probably safe and may have a positive influence on a wide range of perioperative markers of clinical outcome. Further studies are required to determine its cost effectiveness.     

Alcohol acute intoxication before sepsis impairs the wound healing of intestinal anastomosis: rat model of the abdominal trauma patient

Introduction

Most trauma patients are drunk at the time of injury. Up to 2% of traumatized patients develop sepsis, which considerably increases their mortality. Inadequate wound healing of the colonic repair can lead to postoperative complications such as leakage and sepsis.

Objective

To assess the effects of acute alcohol intoxication on colonic anastomosis wound healing in septic rats.

Methods

Thirty six Wistar rats were allocated into two groups: S (induction of sepsis) and AS (alcohol intake before sepsis induction). A colonic anastomosis was performed in all groups. After 1, 3 or 7 days the animals were killed. Weight variations, mortality rate, histopathology and tensile breaking strength of the colonic anastomosis were evaluated.

Results

There was an overall mortality of 4 animals (11.1%), three in the group AS (16.6%) and one in the S group (5.5%). Weight loss occurred in all groups. The colon anastomosis of the AS group didn’t gain strength from the first to the seventh postoperative day. On the histopathological analysis there were no differences in the deposition of collagen or fibroblasts between the groups AS and S.

Conclusion

Alcohol intake increased the mortality rate three times in septic animals. Acute alcohol intoxication delays the acquisition of tensile strength of colonic anastomosis in septic rats. Therefore, acute alcohol intoxication before sepsis leads to worse prognosis in animal models of the abdominal trauma patients.

     

Efficacy and safety of daclatasvir‐based antiviral therapy in hepatitis C virus recurrence after liver transplantation. Role of cirrhosis and genotype 3. A multicenter cohort study

Direct‐acting antiviral agents (DAA) combining daclatasvir (DCV) have reported good outcomes in the recurrence of hepatitis C virus (HCV) infection after liver transplant (LT). However, its effect on the severe recurrence and the risk of death remains controversial. We evaluated the efficacy, predictors of survival, and safety of DAC‐based regimens in a large real‐world cohort. A total of 331 patients received DCV‐based therapy. Duration of therapy and ribavirin use were at the investigator's discretion. The primary end point was sustained virological response (SVR) at week 12. A multivariate analysis of predictive factors of mortality was performed. Intention‐to‐treat (ITT) and per‐protocol SVR were 93.05% and 96.9%. ITT‐SVR was lower in cirrhosis (n = 163) (96.4% vs. 89.6% P = 0.017); the SVR in genotype 3 (n = 91) was similar, even in advanced fibrosis (96.7% vs. 88%, P = 0.2). Ten patients (3%) experienced virological failure. Therapy was stopped in 18 patients (5.44%), and ten died during treatment. A total of 22 patients (6.6%) died. Albumin (HR = 0.376; 95% CI 0.155–0.910) and baseline MELD (HR = 1.137; 95% CI: 1.061–1.218) were predictors of death. DCV‐based DAA treatment is efficacious and safe in patients with HCV infection after LT. Baseline MELD score and serum albumin are predictors of survival irrespective of viral response.     

Efficacy, Tolerance, and Safety of Mammalian Target of Rapamycin Inhibitors as Rescue Immunosuppressants in Liver Transplantation

Background

Mammalian target of rapamycin (mTOR) inhibitors behave as potent immunosuppressants which have the advantages, with respect to calcineurin inhibitors (CNI: cyclosporine or tacrolimus), of no nephrotoxicity and inhibition of cell proliferation. They are particularly suitable for patients with renal insufficiency or neoplasias.

Materials and Methods

Twenty-two liver transplant patients were immunosuppressed with everolimus or sirolimus as rescue therapy after CNI treatment: 7 hepatocellular carcinomas; 5 de novo malignancies; 4 renal insufficiencies; 4 chronic rejections; and 2 acute rejection episodes.

Results

There were 16.7% tumor recurrences, and 25% improvements in renal function, 75% in chronic rejection, and 50% in acute rejection. There was no incidence of rejection, kidney failure, gastrointestinal intolerance, hydrocarbon intolerance, hypertension, or arterial or venous thrombosis. We observed incidences of 50% for hypercholesterolemia, 31.8% for hypertriglyceridemia, 22.7% for thrombocytopenia, 18.2% for leukopenia, and 9.1% for anemia. The intercurrent infection rate was 13.6%, including oral thrush in 13.6%. Lower limb edema occurred in 13.6%, with 1 case of facial edema and 1 of alopecia.

Conclusions

mTOR inhibitors were safe immunosuppressive drugs whose side effects were controlled and easily managed. They have advantages with respect to CNI due to their slight effects on kidney function and lack of promotion of diabetes mellitus. Although their long-term effectiveness for control of neoplastic diseases is yet to be seen, they can be used safely in these patients with no incidence of rejection. Their effectiveness to control chronic rejection seems significant, but it is doubtful for steroid-resistant acute rejection episodes.     

Coronary calcification and its association with mortality in haemodialysis patients

Aim:   Coronary artery calcification (CAC) has been associated with higher mortality in chronic renal disease. The purpose of this study was to assess coronary artery calcium score (CaCs) in haemodialysis patients and to correlate calcium scores with clinical parameters and mortality.
Methods:   A cross-sectional study was conducted in 59 haemodialysis patients. CaCs was assessed by multidetector-row computed tomography and stratified as: CaCs of less than 10 Agatston units (U), no calcification; CaCs of 10–400 U, mild-to-moderate; and CaCs of more than 400 U, severe calcification. The effects of age, haemodialysis duration and biochemical and inflammatory markers on CaCs logarithm were evaluated by multiple linear regression analysis. Cox regression analysis was used to measure the impact of CaCs of more than 400 on 2-year mortality.
Results:   Coronary calcifications were detected in 64.5% of patients, and the median of CaCs was 31.7 U (0–589.7) with a range of 0–5790.0 U. Twenty-one (35.5%) patients had mild-to-moderate and 17 (29%) severe CaCs. Patients with severe CaCs were older and showed a higher prevalence of ischaemic heart disease and a higher body mass index ( P  = 0.04). A trend towards higher C-reactive protein levels was found in patients with severe CaCs. Advanced age was the only variable that influenced CaCs logarithm independently. The effect of severe CaCs on 2-year mortality did not persist after adjustment for other covariates.
Conclusion:   Coronary calcification was highly prevalent in these uraemic patients on chronic haemodialysis. A correlation was evidenced between CaCs and advanced age, but severity of the CAC score did not have an impact on 2-year mortality of this cohort.     

The use of ablative lasers in the treatment of facial melasma

Melasma represents a pigmentary disorder that is difficult to treat. This study aimsto broadly review the use of ablative lasers (Er:YAG and CO2) in the treatment ofmelasma, presenting the level of evidence of studies published to date. A total of 75patients were enrolled in four case series studies (n=39), one controlled clinicaltrial (n=6) and one randomized controlled clinical trial (n=30). Studies on theEr:YAG laser showed better results with the use of short square-shaped pulses, whichdetermined low rates of post-inflammatory hyperpigmentation and long-lastingmaintenance of results. Likewise, studies on the CO2 laser proved the benefits ofshort pulse duration along with low-density energy. Post-treatment maintenance withthe use of antipigmenting creams was necessary and effective to sustain long-termresults. Ablative lasers may represent another useful and effective tool againstmelasma. Postinflammatory hyperpigmentation and difficulty in sustaining long-termresults still represent the main limitations to a broader use of ablative lasers.Based on actual evidence, the use of this technology should be restricted to patientswith recalcitrant disease. Further studies will help establish optimal laserparameters and treatment regimens.     

Effect of cariogenic biofilm challenge on the surface hardness of direct restorative materials in situ

Objectives

The presence of cariogenic biofilm could result in surface degradation of composite and ionomeric restorative materials. Thus, this study evaluated in situ the alterations in the surface microhardness of these materials under biofilm accumulation and cariogenic challenge.

Methods

In a split-mouth, double-blind, cross-over study, 10 volunteers wore palatal intra-oral devices containing bovine enamel slabs restored with composite resin (CR – Z250) or resin-modified glass ionomer (RMGI – Vitremer). Two phases of 14 days were carried out, one for each restorative material. In one side of the device, biofilm was allowed to accumulate under a plastic mesh, whereas in the opposing side, regular brushing was carried out 3 times/day with a dentifrice containing 1100 μg F/g as NaF. A 20% sucrose solution was applied extra-orally 10×/day on each restored dental slab. Knoop microhardness was used to calculate the percentage of surface hardness loss (%SHL).

Results

All materials showed a decrease in surface hardness after the in situ period. The restorative materials presented the following average for %SHL: RMGI without biofilm accumulation = 8.9 and with biofilm accumulation = 25.6, CR without biofilm accumulation = 14.7 and with biofilm accumulation = 17.0.

Conclusion

Biofilm accumulation and the presence of cariogenic challenge promoted faster degradation of ionomeric materials, but this was not observed for composite resin.

Clinical significance

The oral environment affects the surface hardness of aesthetic restorative materials. Biofilm accumulation and cariogenic challenge promote surface degradation for ionomeric materials, but not for composite resin.     

Numerical analysis of the biomechanical behaviour of a weakened root after adhesive reconstruction and post-core rehabilitation

Objectives

The purpose of this study was to perform a finite element analysis to determine whether adhesive reconstruction is able to restore the original biomechanical behaviour of weakened roots, in terms of fracture resistance, when compared with post/crown-restored teeth with intact roots.

Methods

A three-dimensional model of a maxillary central incisor was created. The model simulated an endodontically treated tooth restored with a glass-fibre post, a composite-resin core and a metal crown (Model 1). Based on Model 1, a new volume was created in the root cervical third that represented the area where the dentine structure was lost, resulting in a structurally damaged root (Model 2). A 100 N load was applied to the palatal surface at 130° from the long axis of the tooth. After processing (Ansys^® 10.0 – Canonsburg, PA, USA), the principal normal stress data were analyzed (S1, tensile; S3, compressive).

Results

The models demonstrated a similar S1 distribution concentrated in the lingual cervical region but different S1 levels (Model 1: 28.7 MPa; Model 2: 35.3 MPa). The S3 distribution indicated differences in behaviour between the models (Model 1: −18 to −27 MPa along the buccal root surface; Model 2: −25 to −32 MPa on the post buccal surface and along the buccal root wall).

Conclusions

Although the stress distribution within the root walls remained below the ultimate stress limit of the root dentine, the adhesive reconstruction of the weakened roots did not recover the load resistance of structurally intact roots.

Clinical significance

The decision of when to prosthetically rehabilitate weakened roots with cervical dentine structural tissue loss is a challenge for clinicians. A ‘monoblock’ adhesive reconstruction has been proposed for root reinforcement. During treatment planning, the possibility of restoring the mechanical resistance of the root must be evaluated if successful long-term results are to be achieved.     

Chemoattractant-induced changes in surface expression and redistribution of a functional ligand for P-selectin on neutrophils

Adhesion between platelets and neutrophils is mediated through the interaction of P-selectin on activated platelets with a carbohydrate- containing structure on neutrophils, and occurs under both static and shear conditions. Recent studies using flow chambers have shown that neutrophils become activated after binding to surface-adherent platelets expressing P-selectin. The objective of the present study was to investigate the effect of such activation on the interactions of platelet P-selectin with its ligand on neutrophils. Flow cytometric analyses using P-selectin chimeras revealed that activation induced a rapid and marked reduction in chimera binding, with levels of binding decreased by 71% after 15 minutes of stimulation with the chemotactic agent, FMLP. Using a visual assay of platelet-neutrophil rosetting, we showed that the P-selectin ligand was translocated and clustered at the uropod of neutrophils following the shape changes and polarization induced by chemotactic stimulation. Activated neutrophils bound to surface-adherent platelets also displayed the clustering of P-selectin ligand at the uropod, and these neutrophils detached from the platelets when a shear stress (2 dynes/cm2) was applied through the adhesion chamber. These results indicate that chemotactic stimulation of neutrophils induces changes in the surface expression and distribution of a biologically relevant ligand for P-selectin, and that these changes might influence the adhesive interactions occurring between neutrophils and activated platelets.