Internal post-bariatric hernia due to hepatic adhesion: a case report

ABSTRACT Roux-en-Y gastric bypass, a procedure proven effective for treating morbid obesity and metabolic disorders, carries the risk of complications such as the formation of internal hernias. These hernias are often difficult to diagnose and can be potentially fatal because they can cause structural obstruction. Most internal hernias occur in the jejunojejunostomy mesentery space, followed by Petersen's space hernias, although herniation at other locations can also occur. Our case report presents an example of a rare internal hernia after laparoscopic Roux-en-Y gastric bypass. A 36-year-old woman presented with an uncommon internal hernia located between the liver and alimentary loop, resulting in the formation of a new space and consequently incarcerating the entire biliopancreatic loop. This type of internal hernia is rare and has not been reported in the literature, indicating that this is the first report of such a case. In this case, we realized that the diagnosis was challenging and imaging examinations could not help determine the etiology of the pain and obstruction. Therefore, videolaparoscopy revealed an uncommon hernia formed by firm adhesion between the hepatic segment III and the alimentary loop mesentery. Our case is an example of an internal hernia that was not detected with a normal computed tomography scan of the abdomen and pelvis. Only diagnostic laparoscopy revealed herniation, effectively preventing further complications for the patient.

Robotic approach to remove four tailgut cyst cases in Brazil: a case series

ABSTRACT Tailgut cysts are rare congenital lesions that are remnants of the embryonic hindgut. This abnormality presents with non-specific symptoms or no symptoms; therefore, misdiagnosis is common. Here, we present four cases of tailgut cysts that were successfully removed using a robotic surgical approach. A 42-year-old woman with tenesmus, pain in the right gluteal region, and discomfort in the rectal region during evacuation was referred to our medical center. Another patient was a 28-year-old woman who presented with the same symptoms to our general practitioner. Both patients underwent upper abdominal and pelvic magnetic resonance imaging that revealed a tailgut cyst. Further, a 36-year-old woman was referred with coccyx and hypogastric pain. Magnetic resonance imaging revealed two pararectal cystic formations. She underwent robot-assisted surgery, and after analysis by a pathologist, the conclusion was that the tailgut cyst was associated with scarring fibrosis. A 55-year-old woman with posterior epigastric pelvic pain associated with heartburn underwent robot-assisted surgery to resect a retroperitoneal tumor. These cases highlighted the importance of tailgut cysts in the differential diagnosis of rectal lesions. Surgical treatment is preferred because malignant transformations can occur. The difference between laparoscopic and robotic approaches is the better visualization and stability of the latter, inducing less tissue damage. Robotic resection is a safe procedure, especially in patients with a narrow pelvis, because it reduces tissue damage.

Evaluation of the anti-inflammatory and antioxidant effects of the sucralfate in diversion colitis / Avaliação dos efeitos anti-inflamatório e antioxidante do sucralfato na colite de exclusão

Objective: To evaluate the anti-inflammatory and antioxidant effects of sucralfate enemas in diversion colitis model. Method: Thirty-six Wistar rats underwent intestinal bypass by end colostomy in the descending colon and distal mucous fistula. The animals were divided into 3 experimental groups according to the daily dose of enemas received containing 0.9% SF, sucralfate enemas or sucralfate enemas 1 g/kg/day or 2 g/kg/day. Each group was divided into two subgroups according to euthanasia to be performed 2-4 weeks after derivation. The tissue grade of inflammation was assessed histologically, and neutrophil infiltration by the tissue expression of myeloperoxidase (MPO) identified by immunohistochemistry and quantified by computerized morphometry. Oxidative stress was measured by tissue levels of malondialdehyde (MDA). To compare the results the Student's t test variance was used, and also the variance by ANOVA test, establishing a level of significance of 5% (p< 0.05) for both. Results: The intervention with sucralfate enemas showed improvement in the intensity of tissue inflammation related to the concentration used and the duration of the intervention. Intervention with sucralfate enemas reduced the tissue levels of MPO, independent of concentration or time of intervention (p< 0.01). There was a reduction of MDA levels in animals irrigated with sucralfate enemas, independent of concentration or duration of the intervention (p< 0.01). Conclusion: Enemas with sucralfate enemas reduce inflammation, neutrophil infiltration and oxidative stress in the excluded colon suggesting topical application of the substance to be a valid therapeutic option for the treatment of diversion colitis. (AU)

Objetivo: Avaliar os efeitos anti-inflamatórios e antioxidantes do SCF em modelo de colite de exclusão. Método: Trinta e seis ratos, foram submetidos a derivação intestinal por colostomia terminal no cólon descendente e fistula mucosa distal. Os animais foram divididos em 3 grupos experimentais segundo receberem clisteres diários com SF 0,9%, SCF 1 g/kg/dia ou SCF 2 g/kg/dia. Cada grupo foi dividido em dois subgrupos segundo a eutanásia ser realizada após 2 ou 4 semanas da derivação. O grau de inflamação tecidual foi avaliado por estudo histológico e a infiltração neutrofílica pela expressão tecidual de mieloperoxidase (MPO) identificada por imunoistoquímica e quantificada por morfometria computadorizada. O estresse oxidativo foi mensurado pelo conteúdo de malondialdeído (MDA). Para análise dos resultados utilizou-se os teste t de Student, e ANOVA, estabelecendo-se para todos os testes nível de significância de 5% (p< 0,05). Resultados: A intervenção com SCF melhorou o grau de inflamação tecidual relacionando-se a concentração utilizada e ao tempo de intervenção. A intervenção com SCF reduziu os níveis teciduais de MPO, independente da concentração ou do tempo de intervenção (p< 0,01). Houve redução dos níveis de MDA nos animais irrigados com SCF, independente da concentração ou tempo de intervenção (p< 0,01). Conclusão: Enemas com SCF reduzem o processo inflamatório, infiltrado neutrofílico e estresse oxidativo no cólon excluso sugerindo que a substância possa se tornar uma opção terapêutica válida para o tratamento da colite de exclusão. (AU)

Tissue content of sulfomucins and sialomucins in the colonic mucosa, without fecal stream, undergoing daily intervention with sucralfate

PURPOSE: To measure the content of acidic mucin, sialomucin, and sulfomucins in the colonic mucosa without fecal stream submit to intervention with sucralfate (SCF). METHODS: Thirty-six rats were submitted to a right colostomy and a distal mucous fistula and divided into two groups according to sacrifice to be performed two or four weeks. Each group was divided into three subgroups according daily application of enemas containing saline, SCF at 1.0 g/kg/day or 2.0 g/kg/day. Colitis was diagnosed by histological analysis. Acid mucins were determined with the Alcian-Blue and sulfomucin and sialomucin by high iron diamine-alcian blue (HID-AB) techniques. The mucins were quantified by computer-assisted image analysis. Mann-Whitney and ANOVA tests were used to analyze the results establishing the level of significance of 5% for both (p<0.05). RESULTS: SCF enemas decreased the inflammation score and was related to the concentration used and time of the intervention. SCF at both concentrations increased the content of acid mucin, which was related to the concentration used and to the improvement in the inflammatory score. There was an increase in the content of sulfomucins and sialomucins in SCF groups. SCF increased sulfomucins from 2 weeks of intervention, which was not related to the dose or time of application. The increase in sialomucin content was related to the time and dose used in the intervention. CONCLUSION: Sucralfate increased the content of acidic mucins, primarily at the expense of sialomucin, which was affected by the dose and time of intervention. .

Oral administration of curcumin (Curcuma longa) can attenuate the neutrophil inflammatory response in zymosan-induced arthritis in rats

PURPOSE: To evaluate the effect of curcumin in the acute phase of zymosan-induced arthritis. METHODS: Twenty-eight male rats were subjected to intra-articular infiltration of zymosan of both knees and, in four the infiltration was made with saline. The animals were divided into five groups second received every six hours by gavage: corn oil by (positive and negative control); curcumin (100 mg/kg); prednisone 1 mg/kg/day; prednisone 8 mg/kg. All animals were sacrificed after six, 12, 24 and 48 hours of the infiltration. The knees were removed for evaluation of neutrophil infiltration. The number of neutrophils was counted by computer-assisted analysis of the images. The neutrophil infiltrate was stratified into four grades: 0 = normal; + = mild; ++/+++ = moderate; > ++++ = severe. The results were compared using the Mann-Whitney test and the variance by Kruskal-Wallis test adopting a significance level of 5% (p<0.05). RESULTS: Curcumin reduces inflammatory activity in the first six hours after zymosan-induced arthritis when compared to saline (p<0.01). This was also observed in animals subjected to administration of prednisone (1 mg/kg) and those treated with prednisone (8 mg/kg). Curcumin was more effective than lower doses of prednisone in the first six hours after induction of the arthritis. After 12, 24 and 48 hours, curcumin does not have the same anti-inflammatory effects when compared to prednisone. After 48 hours, prednisone is more effective than curcumin in reducing the inflammatory infiltrate regardless of the dose of prednisone used. CONCLUSION: Oral administration of curcumin reduces inflammation in the first six hours after experimentally zymosan-induced arthritis. .

Evaluation of the application of enemas containing sucralfate in tissue content of neutral and acid mucins in experimental model of diversion colitis

PURPOSE: To evaluate the effects of sucralfate on tissue content of neutral and acids mucins in rats with diversion colitis. METHODS: Thirty-six rats were submitted to a proximal right colostomy and a distal mucous fistula. They were divided into two groups according to sacrifice to be performed two or four weeks after intervention. Each group was divided into three subgroups according daily application of enemas containing saline, sucralfate at 1.0 g/kg/day or 2.0 g/kg/day. Colitis was diagnosed by histological analysis and neutral and acid mucins by Periodic Acid Schiff and Alcian Blue techniques, respectively. The contents of mucins were quantified by computer-assisted image analysis. Student's t paired and ANOVA test were used to compare the contents of both types of mucins among groups, and to verify the variance with time, establishing level of signification of 5% for both (p<0.05). RESULTS: Enemas containing sucralfate improves the inflammation and increases the tissue contents of neutral and acid mucins. The content of neutral mucins does not change with the time or concentration of sucralfate used, while acid mucins increases with concentration and time of intervention. CONCLUSIONS: Sucralfate enemas improve the inflammatory process and increase the tissue content of neutral and acid mucins in colon without fecal stream. .

Evaluation of sucralfate enema in experimental diversion colitis / Avaliação dos efeitos da aplicação de enemas com sucralfato em modelo experimental de colite de exclusão

Diversion colitis (DC) is an inflammatory disease that develops in segments with fecal diversion. Sucralfate (SCF) complex, which consists of sucrose octasulfate and polyaluminum hydroxide, has been demonstrated to be effective in the treatment of different forms of colitis. However, until now, the effects of SCF have not been evaluated in DC. OBJECTIVE: to evaluate whether the use of enemas containing SFC improves histological findings in experimental DC. METHODS: Thirty-six rats underwent right colon bypass procedure through the creation of a proximal colostomy and a distal mucous fistula. The animals were divided into two groups according to the euthanization procedure to be performed two to four weeks after surgery. Each experimental group was divided into three subgroups of six animals, which were submitted to daily application of enemas containing saline solution 0.9% or SCF at concentrations of 1.0 g/kg/day or 2.0 g/kg/day, respectively. The diagnosis of DC in segments with fecal diversion was established by histopathological study considering the following variables: epithelial loss, formation of crypt abscesses, the population of goblet cells, inflammatory infiltrate and presence of fibrosis. For statistical analysis, the nonparametric Mann-Whitney and Kruskal-Wallis tests were used, with a significance level of 5% (p <0.05). RESULTS: It was observed that the daily application of SCF enemas decreased epithelial loss, formation of colon crypt abscesses, inflammatory infiltrate and tissue fibrosis (p <0.05), unrelated to time of intervention. The intervention with SCF preserves the goblet cell population. The effects of the substance on the preservation of colonic epithelium; the decrease in the inflammatory process and subsequent abscess formation in the colon crypts are associated with the concentration used, whereas tissue fibrosis decrease is associated with the concentration and time of intervention. CONCLUSION: Preventive application of SCF enemas reduces the inflammatory process in the colon with fecal diversion. (AU)

A colite de exclusão (CE) é uma doença inflamatória que se desenvolve em segmentos desprovidos de trânsito fecal. O sucralfato (SCF) complexo formado pelo octossulfato de sacarose e hidróxido de polialumínio vem se demonstrando eficaz para o tratamento de diferentes formas de colite, porém, até a presente data, os efeitos do SCF ainda não foram avaliados na CE. OBJETIVO: avaliar se a aplicação de clisteres contendo SFC melhora as alterações histológicas encontradas em modelo experimental de CE. MÉTODOS: trinta e seis ratos foram submetidos à derivação do trânsito no cólon direito pela confecção de colostomia proximal e fístula mucosa distal. Os animais foram divididos em dois grupos experimentais de acordo com o sacrifício ser realizado após duas ou quatro semanas do procedimento cirúrgico. Cada grupo experimental foi dividido em três subgrupos de seis animais segundo terem sidos submetidos à aplicação diária com enemas contendo solução fisiológica a 0,9% ou SCF nas concentrações de 1,0g/kg/dia ou 2,0 g/kg/dia. O diagnóstico de CE nos segmentos sem trânsito foi estabelecido por estudo histopatológico considerando-se as seguintes variáveis: perda epitelial, formação de abscessos nas criptas, população de células caliciformes, infiltrado inflamatório e a presença de fibrose. Para análise estatística adotou-se os testes não paramétricos de Mann-Withney e Kruskal-Wallis estabelecendo-se para ambos, nível de significância de 5% (p < 0,05). RESULTADOS: verificou-se que a aplicação diária de enemas com SCF diminui a perda epitelial, a formação de abscessos nas criptas cólicas, o infiltrado inflamatório e a presença de fibrose tecidual (p < 0,05), não relacionada ao tempo de intervenção. A intervenção com SCF preserva a população de células caliciformes. Os efeitos da substância na preservação do epitélio cólico, na redução do processo inflamatório e consequente formação de abscessos nas criptas cólicas encontram-se relacionado à concentração utilizada, enquanto a redução da fibrose tecidual a concentração e ao tempo de intervenção. CONCLUSÃO: a aplicação preventiva de enemas com SCF reduz o processo inflamatório em segmentos cólicos desprovidos de transito intestinal. (AU)

Primary epiploic appendagitis / Apendagite epiplóica primária

Primary epiploic appendagitis (PEA) is a seldom reported disease caused by spontaneous torsion of one or more epiploic appendices. The aim of this study is to describe two cases of PEA reviewing the main aspects of the diagnosis and treatment of disease. Case report: Case 1) Male patient, 55 years old, obese, with abdominal right iliac fossa (RIF) pain for two days. Abdominal examination showed pain on palpation in the RIF with rebound tenderness. Abdominal computed tomography identified lobulated lesion in the cecum, measuring 4.5 cm in diameter, which was suggestive of PEA or early neoplasm of the colon wall. The laparoscopic assessment confirmed the diagnosis of PEA and the appendix was removed. The patient had a satisfactory outcome, being discharged on the second postoperative day. Case 2) Female patient, obese, 47 years old, with abdominal pain for six days, with sudden RIF onset. She had pain at palpation with rebound tenderness. Acute diverticulitis was suspected and patient underwent abdominal CT that identified PEA in the sigmoid colon. After expectant management, the patient showed progressive improvement resuming her activities in seven days. PEA is a rarely recalled condition during the investigation of inflammatory acute abdomen which can be easily recognized by modern imaging methods of assessment. (AU)

Apendagite epiplóica primária (AEP) é uma enfermidade raramente descrita, ocasionada pela torção espontânea de um ou mais apêndices epiplóicos. O objetivo deste estudo é descrever dois casos de AEP revisando os principais aspectos do diagnóstico e tratamento da doença. Relato dos Casos: 1º) Homem, 55 anos, obeso com dor abdominal em FID há dois dias. No exame do abdômen apresentava dor à palpação na FID e descompressão brusca presente. A tomografia computadorizada do abdômen identificou lesão expansiva no ceco, lobulada, medindo 4,5 cm de diâmetro, suspeitando-se de AEP ou neoplasia primitiva da parede cólica. Durante a videolaparoscopia confirmou-se o diagnóstico de AEP sendo removido o apêndice comprometido. O doente apresentou evolução satisfatória recebendo alta no segundo dia. 2º) Mulher, obesa, 47 anos, com dor abdominal há seis dias, de início súbito na fossa ilíaca esquerda. Apresentava dor à palpação local com descompressão brusca presente. Com suspeita de diverticulite aguda foi submetida à TC do abdômen que identificou AEP do cólon sigmóide. Após conduta expectante apresentou melhora progressiva retomando suas atividades em sete dias. A AEP é uma enfermidade raramente suspeitada durante a investigação do abdômen agudo inflamatório, que pode ser reconhecida com facilidade pelos modernos exames de imagem. (AU)

Oxidative stress and changes in the content and pattern of tissue expression of ß-catenin protein in diversion colitis

OBJECTIVE: The aim of this study is to verify if oxidative stress is related to changes in content and pattern of β-catenin protein expression in an experimental model of diversion colitis. METHODS: Sixty Wistar rats were submitted to intestinal bypass. The animals were divided into three groups according to the sacrifice to take place in six, 12 and 18 weeks. For each group, five animals only underwent laparotomy (control). The presence of colitis was diagnosed by histological study, and its severity, by inflammation grading scale. Cellular oxidative stress was measured by comet assay. Tissue expression of β-catenin protein was analyzed by the immunohistochemistry and quantification of its tissue content by computerized morphometry. Statistical analysis was performed with the Student's t-test, median, Mann-Whitney, ANOVA and Kruskal-Wallis, adopting a significance level of 5% (p <0.05). RESULTS: Colon segments without fecal stream developed colitis, which worsened with time of exclusion. Segments without fecal stream suffer higher levels of oxidative stress when compared to those with stream, and it worsens with time of exclusion. The levels of cellular oxidative stress are directly related to the degree of inflammation. The total content of ß-catenin in segments without fecal stream reduces after six weeks, and does not vary thereafter. The content of β-catenin in the apical portion of the colon crypts decreases with time, whereas in the basal region, it increases. The total content of ß-catenin is inversely related to the degree of inflammation and levels of tissue oxidative stress levels. CONCLUSION: There are changes in tissue content of E-cadherin and increased expression of ß-catenin in proliferative regions of colonic crypts, related with oxidative tissue stress. (AU)

OBJETIVO: O objetivo do presente estudo é avaliar a relação entre estresse oxidativo e conteúdo tecidual de β-catenina em modelo experimental de colite de exclusão. MÉTODOS: Sessenta ratos Wistar foram submetidos à derivação intestinal e divididos em três grupos experimentais segundo o sacrifício ser realizado em 6, 12 e 18 semanas. Para cada grupo, cinco animais foram submetidos apenas a laparotomia (controle). A colite foi diagnosticada por estudo histológico, enquanto sua intensidade por escala de graduação inflamatória. Os níveis de estresse oxidativo foram mensurados pelo ensaio cometa, enquanto a expressão e o conteúdo tecidual de ß-catenina por imunoistoquímica e morfometria computadorizada, respectivamente. Os resultados foram analisados pelos testes t de Student, Mann Whitney, ANOVA e Kruskal-Wallis, estabelecendo-se nível de significância de 5% (p<0,05). RESULTADOS: Nos segmentos sem trânsito fecal ocorre desenvolvimento de colite que piora com o tempo de exclusão. Segmentos sem trânsito sofrem maiores níveis de estresse oxidativo quando comparados àqueles com trânsito, piorando com o tempo de exclusão. Os níveis de estresse oxidativo encontram-se diretamente relacionados a piora da inflamação. O conteúdo total de ß-catenina no cólon sem trânsito reduz após seis semanas de exclusão. O conteúdo de ß-catenina no ápice das criptas cólicas diminui com o tempo, enquanto na região basal, aumenta. O conteúdo total da β-catenina encontra-se inversamente relacionado ao grau de inflamação e aos níveis de estresse oxidativo. CONCLUSÃO: Existe redução no conteúdo de ß-catenina, principalmente no ápice das glândulas cólicas e aumento nas regiões basais, relacionadas à piora do estresse oxidativo. (AU)