Síndrome de Rapunzel: atadura sicológica y simulación orgánica / Rapunzel syndrome: psychological bondage and organic simulation

Introducción. El síndrome de Rapunzel es una entidad infrecuente, que se presenta como un tricobezoar a causa de una aglomeración de cabello acumulado dentro del tracto gastrointestinal, por lo que simula otras patologías quirúrgicas. Caso clínico. Paciente femenina de 10 años de edad, con tricotilomanía y tricofagia, dolor abdominal y síntomas inespecíficos de obstrucción intestinal de ocho meses de evolución. Al examen físico se encontró abdomen con distensión y masa palpable en epigastrio y mesogastrio. La ecografía permitió hacer el diagnóstico de tricobezoar gástrico extendido hasta el intestino delgado, por lo que se llevó a cirugía para gastrotomía y se extrajo el tricobezoar, con evolución satisfactoria de la paciente. El abordaje integral permitió conocer la atadura sicológica por posible maltrato infantil. Resultado. La paciente tuvo una evolución satisfactoria y se dio egreso al quinto día de hospitalización. Actualmente se encuentra en seguimiento por sicología, siquiatría infantil y pediatría. Discusión. El caso clínico denota la importancia en reconocer situaciones de presentación infrecuente en pediatría, que puedan estar asociadas a alteraciones sicológicas o presunción de maltrato infantil y que se presenten como una condición orgánica recurrente que simule otras patologías abdominales frecuentes en la infancia. El retraso diagnóstico puede conducir a un desenlace no deseado con complicaciones. Conclusión. Se hace mandatorio el manejo integral del paciente pediátrico y aumentar la sensibilidad para reconocer situaciones de presunción de maltrato infantil, sobre todo en pacientes con una condición orgánica quirúrgica recurrente.

Introduction. Rapunzel syndrome is an uncommon condition that manifests as trichobezoars, which are hair bundles in the stomach or small intestine that can mimics other surgical illnesses. Multiple complications can arise from delayed diagnosis and treatment. Clinical case. A 10-year-old female patient with trichotillomania and trichophagia, with abdominal pain and nonspecific symptoms of intestinal obstruction of eight months of evolution. Physical examination revealed epigastric tenderness and a solid mass was palpable in the mesogastric and epigastric region. An abdominal ultrasound showed gastric trichobezoar that extended into the small intestine. A gastrotomy was performed and the trichobezoar was extracted with satisfactory evolution of the patient. The comprehensive approach allowed knowing the psychological bond due to possible child abuse. Results. The patient had a satisfactory evolution and was discharged on the fifth day of hospitalization. He is currently being monitored by psychology, child psychiatry and pediatrics. Discussion. This clinical case highlights the importance of recognizing situations that seldom present in pediatrics, which may have a psychological aspect due to the presumption of child abuse, and which present as a recurrent organic condition simulating other frequent abdominal pathologies in childhood; all of which may lead to an unwanted outcome due to diagnostic delay. Conclusion. The comprehensive management of the pediatric patient is mandatory to recognize situations of presumed child abuse, in the face of a recurrent surgical conditions.

Partial distal duodenectomy in patient with adenocarcinoma / Duodenectomia distal parcial em paciente com adenocarcinoma

ABSTRACT BACKGROUND: Duodenal adenocarcinoma is a small percentage of gastrointestinal neoplasms, around 0.5%, and its treatment is based on resection of the tumor, classically by pancreaticoduodenectomy. In recent years, however, segmental resections of duodenal lesions, that do not involve the second portion or the periampullary region, have gained relevance with good surgical and oncological outcomes as well as the benefit of avoiding surgeries that can result in high morbidity and mortality. AIMS: To report a case of an elderly female patient with malignant neoplastic lesion in the third and fourth duodenal portion, non-obstructive, submitted to surgical treatment. METHODS: The technical option was the resection of the distal duodenum and proximal jejunum with preservation of the pancreas and reconstruction with side-to-side duodenojejunal anastomosis. RESULTS: The evolution was satisfactory and the surgical margins were free of neoplasia. CONCLUSIONS: Segmental resections of the duodenum are feasible and safe, offering the benefit of preventing complications of pancreaticoduodenectomies.

RESUMO RACIONAL: O adenocarcinoma duodenal é uma pequena porcentagem das neoplasias gastrointestinais, em torno de 0,5%, e seu tratamento baseia-se na ressecção da massa tumoral, classicamente por pancreatoduodenectomia. Nos últimos anos, porém, as ressecções segmentares de lesões duodenais que não envolvem a segunda porção ou a região periampular têm ganhado relevância com bons resultados cirúrgicos e oncológicos e com o benefício de evitar uma cirurgia que pode apresentar alta morbimortalidade. OBJETIVOS: Reportar o caso de uma paciente feminina, idosa, com lesão neoplásica maligna na terceira e quarta porção duodenal, não obstrutiva, submetida a tratamento cirúrgico. MÉTODOS: A opção técnica foi a ressecção do duodeno distal e jejuno proximal com preservação do pâncreas e reconstrução com anastomose duodenojejunal látero-lateral. RESULTADOS: A evolução foi satisfatória e as margens cirúrgicas foram livres de neoplasia. CONCLUSÕES: As ressecções segmentares do duodeno são factíveis e seguras, com os benefícios de evitar as complicações das pancreatoduodenectomias.

Infiltrating Lobular Carcinoma of the Breast Metastatic to the Duodenum, about a Case

Introduction: Gastric outlet obstruction or pyloric syndrome can occur secondary to neoplastic involvement, and metastasis as an etiology is unusual. Breast neoplasms generally cause bone, liver, and lung metastases, rarely involving the gastrointestinal tract. Case presentation: A 69-year-old female patient with infiltrating lobular carcinoma of the right breast consulted for abdominal pain and postprandial emetic episodes with oral intolerance and dyspnea. Bilateral neoplastic breast involvement and dilation of the gastric chamber with thickening of the pylorus were recorded. She required antiemetic management and placement of a nasogastric tube. She was taken to an upper digestive tract endoscopy, which found an ulcerated lesion with an infiltrative appearance at the postpyloric level that circumferentially compromised the duodenal lumen. Then, a biopsy was taken, which was compatible with a breast carcinoma of a lobular type. This entity, called pyloric syndrome due to neoplasia, can be managed with gastrojejunostomy or an enteral prosthesis that improves the quality of life of patients with an ominous short-term prognosis. The patient in our case expressed advance directives not to receive invasive procedures, for which an uncovered metal prosthesis was placed for palliative purposes, achieving the re-establishment of the feeding route and resolution of dyspnea due to restriction. Conclusions: The metastatic involvement of neoplasms of the breast to the gastrointestinal tract is rare; however, it should be suspected in elderly patients with previously documented neoplasms.

Introducción: La obstrucción al tracto de salida gástrico o síndrome pilórico puede presentarse de manera secundaria a compromiso neoplásico, y es inusual el compromiso metastásico como etiología. Las neoplasias de la mama generalmente originan metástasis óseas, hepáticas y pulmonares, y es infrecuente el compromiso del tracto digestivo. Presentación del caso: Se trata de una paciente de 69 años con carcinoma lobulillar infiltrante de mama derecha que consultó por dolor abdominal y episodios eméticos posprandiales con intolerancia a la vía oral y disnea. Se registró un compromiso neoplásico mamario bilateral y dilatación de la cámara gástrica con engrosamiento del píloro. Se dio manejo antiemético y colocación de sonda nasogástrica. Fue llevada a una endoscopia de vías digestivas altas en la que se encontró una lesión ulcerada de aspecto infiltrativo a nivel pospilórico que comprometía de forma circunferencial la luz duodenal, y luego se tomó una biopsia a este nivel, que fue compatible con un carcinoma mamario de tipo lobulillar. Esta entidad, denominada síndrome pilórico por neoplasias, puede manejarse con gastroyeyunostomía o con prótesis enteral que mejore la calidad de vida en pacientes con pronóstico ominoso a corto plazo. La paciente de nuestro caso manifestó voluntades anticipadas para no recibir procedimientos invasivos, por lo cual se ofreció la colocación de una prótesis metálica descubierta con fines paliativos y se logró el restablecimiento de la vía de alimentación y resolución de la disnea por restricción. Conclusiones: El compromiso metastásico de neoplasias de la mama al tracto digestivo es poco frecuente; sin embargo, debe sospecharse en pacientes de edad avanzada y con neoplasias previamente documentadas.

Síndrome de la arteria mesentérica superior o Síndrome de Wilkie. Presentación de tres casos clínicos y revisión de la literatura

Objetivo: Presentar una causa rara de obstrucción duodenal como es el sindrome de arteria mesentérica superior (SAMS). Material y Método: se presentan tres casos clínicos de sindrome de SAMS. Resultados: el tratamiento médico y nutricional fue exitoso en los primeros dos casos, mientras que en el último fue necesario realizar una derivación quirúrgica. Discusión: en este sindrome, el ángulo aortomesentérico normal se encuentra disminuído, causando la compresión de la tercera porción del duodeno entre la aorta y la arteria mesentérica superior. Esto determina una obstrucción duodenal que se ve más frecuentemente en pacientes con pérdida importante y rápida de peso. Esto determina alteraciones hidroelectrolíticas y desnutrición severas. El tratamiento médico consiste en soporte nutricional y corrección de anormalidades hidroelectrolíticas. Los procedimientos quirúrgicos se reservan frente a los casos de falla del tratamiento médico. Conclusión: el SAMS es una entidad poco frecuente y un reto diagnóstico. El cuadro clínico puede ser grave con desnutrición severa y trastornos hidroelectrolíticos que ponen en riesgo la vida del paciente. El soporte hidroelectrolítico y nutricional, junto a la duodenoyeyunostomía, son los tratamientos de elección.

Aim: To present a rare cause of duodenal obstruction known as the superior mesenteric artery syndrome (SMAS). Material and Method: we present three cases of SMAS. Results: medical and nutritional treatment were effective in the first two cases while in the last case, a derivative procedure was necessary. Discussion: in this syndrome, the normal aortomesenteric angle is narrowed, causing compression of the third portion of the duodenum between the aorta and the superior mesenteric artery. This leads to duodenal obstruction more frequently observed in patients with severe and fast weight loss. Medical treatment consists in nutritional support and correction of hydro electrolyte imbalance. Surgical procedures are reserved for cases with failure of medical treatment. Conclusion: SMAS is a rare entity and a diagnosis challenge. Clinical setting may be severe with extreme malnutrition and life-threatening dehydration and electrolyte disorder. Nutritional support, hydro electrolyte correction, combined with duodenojejunostomy, if necessary, are the treatments of choice.

Malrotación intestinal en el adulto: cirugía de Ladd laparoscópica / Intestinal Malrotation in Adults: laparoscopic Ladd's Surgery

Las malrotaciones por bandas de Ladd son un subtipo de anormalidades de la embriogénesis consistentes en prolongaciones fibrosas, producto de una fijación anómala del mesenterio. Se extienden desde el ciego mal rotado hacia el retroperitoneo, pudiendo producir compresión extrínseca del duodeno. En el 90% de los casos la presentación clínica tiene lugar dentro del primer año de vida como un cuadro agudo, en forma de oclusión duodenal o vólvulo de intestino delgado con la consecuente isquemia de este o hernia interna. En la edad adulta, las formas de presentación son menos específicas. Los métodos de referencia ("gold standard") utilizados para el diagnóstico son la seriada gastroduodenal y la tomografía computarizada. El tratamiento quirúrgico consiste en la cirugía de Ladd, cuyo abordaje convencional fue descripto en 1936 por William Ladd. Presentamos el caso de un paciente adulto con un cuadro oclusivo, causado por dicha anomalía, diagnosticado de forma oportuna y resuelto de manera segura por vía laparoscópica. (AU)

Ladd's band malrotations are a subtype of abnormalities of embryogenesis consisting of fibrous extensions, product of abnormal fixation of the mesentery, that goes from the poorly rotated cecum towards the retroperitoneum, which can cause extrinsic compression of the duodenum. In 90% of cases, the clinical presentation takes place within the first year of life, as an acute condition, like duodenal occlusion or small bowel volvulus with its consequent ischemia or internal hernia. In adulthood, the forms of presentation are less specific. The gold standard methods used for diagnosis are gastroduodenal series and computed tomography. Surgical treatment consists of Ladd's surgery, whose conventional approach was described in 1936 by William Ladd. We present ta case of an adult patient with an occlusive presentation, given by this anomaly, diagnosed in a timely manner and safely resolved by laparoscopic approach. (AU)

La ingesta accidental Quiste de duplicación duodenal en un paciente pediátrico. Reporte de caso

Introducción. Los quistes de duplicación duodenal son malformaciones raras, que ocurren durante el desarrollo embriológico del tracto gastrointestinal. Caso clínico. Se presenta el caso de un niño de tres años, con cuadro clínico de dolor abdominal, náuseas y vómitos. La ecografía y la tomografía computarizada informaron una imagen quística entre el hígado, riñón derecho y colon. Resultados. Se realizó laparoscopia encontrando un quiste de duplicación duodenal con moco en la primera porción del duodeno. Se practicó una resección del quiste y mucosectomía del segmento restante. Conclusión. Los síntomas de un quiste de duplicación duodenal son inespecíficos y su hallazgo frecuentemente es incidental. El tratamiento quirúrgico depende del tamaño, la ubicación y su relación con la vía biliar.

Introduction. Duodenal duplication cysts are rare malformations that occur during the embryological development of the gastrointestinal tract. Clinical case. The case of a three-year-old boy with abdominal pain, nausea, and vomiting is presented. Ultrasound and computed tomography revealed a cyst between the liver, right kidney, and colon. Results. Laparoscopy was performed, finding a duodenal duplication cyst with mucus in the first portion of the duodenum. A resection of the cyst and mucosectomy of the remaining segment were performed. Conclusion. The symptoms of a duodenal duplication cyst are nonspecific and its finding is frequently incidental. Surgical treatment depends on the size, location, and relationship to the bile duct.

Quiste de duplicación duodenal en un paciente pediátrico. Reporte de caso / Duodenal duplication cyst in a pediatric patient. Case report

Introducción. Los quistes de duplicación duodenal son malformaciones raras, que ocurren durante el desarrollo embriológico del tracto gastrointestinal. Caso clínico. Se presenta el caso de un niño de tres años, con cuadro clínico de dolor abdominal, náuseas y vómitos. La ecografía y la tomografía computarizada informaron una imagen quística entre el hígado, riñón derecho y colon. Resultados. Se realizó laparoscopia encontrando un quiste de duplicación duodenal con moco en la primera porción del duodeno. Se practicó una resección del quiste y mucosectomía del segmento restante. Conclusión. Los síntomas de un quiste de duplicación duodenal son inespecíficos y su hallazgo frecuentemente es incidental. El tratamiento quirúrgico depende del tamaño, la ubicación y su relación con la vía biliar.

Introduction. Duodenal duplication cysts are rare malformations that occur during the embryological development of the gastrointestinal tract. Clinical case. The case of a three-year-old boy with abdominal pain, nausea, and vomiting is presented. Ultrasound and computed tomography revealed a cyst between the liver, right kidney, and colon. Results. Laparoscopy was performed, finding a duodenal duplication cyst with mucus in the first portion of the duodenum. A resection of the cyst and mucosectomy of the remaining segment were performed. Conclusion. The symptoms of a duodenal duplication cyst are nonspecific and its finding is frequently incidental. Surgical treatment depends on the size, location, and relationship to the bile duct.

Íleo biliar, causa no habitual de oclusión intestinal

El íleo biliar es una rara complicación de la litiasis vesicular, que se comporta como un cuadro de obstrucción intestinal mecánica, cuya causa es la impactación de uno o más cálculos biliares en su luz. Es evidente que, por lo infrecuente de esta entidad en los servicios quirúrgicos, el diagnóstico de la misma es demorado o no se realiza, incidiendo en la evolución del paciente de manera desfavorable. El objetivo de este trabajo es considerar que un diagnóstico precoz del íleo biliar -basado en el análisis de los antecedentes del enfermo, las manifestaciones clínicas y la interpretación correcta en busca de los signos de la tríada de Rigler- permite una mejor evolución de los pacientes. Los estudios imagenológicos y su interpretación son fundamentales en el diagnóstico de esta entidad.

Biliary ileus is a rare complication of gallbladder lithiasis, which behaves like a mechanic intestinal obstruction, the cause of which is the impaction of one or more gallstones in its lumen. It is evident that because of the infrequency of this entity in the surgical services, its diagnosis is delayed or not carried out, affecting the patient's evolution in an unfavorable way. The aim of this paper is to consider that a precocious diagnosis of biliary ileus-based on the analysis of the patient's history, the clinical manifestations and correct interpretation in search of the signs of Rigler's triad-allows a better evolution of patients. Imaging studies and their interpretation are fundamental in the diagnosis of this entity.

An-unusual-complication-of-liver-abscess—hepatoduodenal-fistula

Liver abscess is an intra-abdominal infection characterized by localized pus collection with destruction of hepatic parenchyma. When a liver abscess ruptures and extends into adjacent structures, it leads to development of complications which further increases mortality rate. Involvement of peritoneal, pericardial and pleural cavity are often noted but, extension into gastro-intestinal tract is rare and unusual; with only a limited number of cases reported, we present a recently encountered case of liver abscess. The abscess was found to be complicated by formation of fistulous tract with duodenum.

Change in prevalence and pattern of peptic ulcer disease in the Northern Savannah of Nigeria: An endoscopic study

Background: Peptic ulcer disease (PUD) is common worldwide. Its incidence and prevalence have been declining in recent years in developed countries, and a similar trend has been observed in many parts of Africa including Nigeria. Aim: This study aimed to provide an endoscopic update on PUD in the Northern Savannah of Nigeria and compare with past reports from the region and recent reports from Nigeria, Africa, and the rest of the world. Methods: Upper gastrointestinal endoscopy records of consecutive patients diagnosed with PUD between January 2014 and September 2022 at an endoscopy unit of a tertiary institution in North West Nigeria were retrieved and demographic data, types of peptic ulcer, and their characteristics were extracted and analyzed. Results: Over a 9 year period, 171/1958 (8.7%) patients were diagnosed with PUD: mean age 48.8 years (range 14­85), 68.4% male, and 70% >40 years. 59.6% were gastric ulcers (GU), 31.6% duodenal ulcers (DU), and 8.8% were both. The mean age of patients with GU was slightly higher than those with DU (49.9 years vs. 46.6 years, P = 0.29); patients aged 40 years significantly more GU than DU (74.6% vs. 54.7%, P = 0.016). There were no significant gender differences between GU and DU. Conclusion: The prevalence and pattern of PUD in Northern Savannah of Nigeria have changed ­ patients were predominantly male and older, and GU predominated.

Bleeding duodenal diverticula managed With surgical resection: A case report

@#The duodenum is the most common extra-colonic site of diverticulum. If present, it rarely manifests with symptoms or complications. A case is discussed involving a 78-year-old female who presented with massive upper gastrointestinal bleeding from duodenal diverticula. Due to hemodynamic instability, she eventually underwent duodenal resection, with a side-to-side duodenojejunostomy as a means of restoring intestinal continuity. The postoperative course was unremarkable. The patient was able to feed enterally and had no recurrence of bleeding.

Clinical Research Advances of Duodenal-Type Follicular Lymphoma--Review / 中国实验血液学杂志

Duodenal-type follicular lymphoma (DFL) is a unique subtype of follicular lymphoma (FL), which often involves the second portion of duodenum (descending part of duodenum). Due to its specific pathological features, such as lack of follicular dendritic cells meshwork and disappearance of activation-induced cytidine deaminase expression, DFL presents an inert clinical course and is often confined to the intestinal tract. Inflammation-related biomarkers suggest that the microenvironment may play a likely role in the pathogenesis and favorable prognosis of DFL. Since patients generally have no obvious clinical symptoms and low progression rate, the treatment regimen for DFL is mainly observation and waiting (W&W) strategy. This study will review the latest research progress of epidemiology, diagnosis, treatment and prognosis of DFL in recent years.

Correlation of the duration of preoperative biliary drainage and postoperative complications after pancreaticoduodenectomy / 肿瘤研究与临床

Objective:To investigate the effect of the duration of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy.Methods:The clinical data of 102 patients with benign and malignant hepatopancreatic ductal periampullary tumors who underwent pancreaticoduodenectomy and preoperative biliary drainage in Beijing Friendship Hospital, Capital Medical University from January 2016 to July 2020 were retrospectively analyzed. According to the median duration of preoperative biliary drainage, the patients were divided into short-term drainage group (≤ the median duration of biliary drainage) and long-term drainage group (> the median duration of biliary drainage). The general data, the effect of biliary drainage, inflammation-related indicators and postoperative complications were compared between the two groups. Multivariate logistic regression was used to screen the risk factors related to the postoperative severe complications.Results:Of the 102 patients, 68 (66.7%) were males and 34 (33.3%) were females, with a median age of 63 years (43-80 years). The median duration of preoperative biliary drainage was 14 d. There were 68 patients in short-term drainage group and 34 patients in long-term drainage group. There were no statistically significant differences in age, gender, body mass index (BMI), hypertension, diabetes mellitus, surgery history of upper abdominal, American Society of Anesthesiologists (ASA) grade, carcinoembryonic antigen, carbohydrate antigen 125, alpha-fetoprotein, prothrombin time, pancreaticojejunostomy method, operation time, and pathological type between the two groups (all P > 0.05). However, patients in long-term drainage group had higher conversion rate, more blood loss and longer hospital stay compared with those in short-term drainage group (all P < 0.05). Before biliary drainage, alanine aminotransferase (ALT) level in short-term drainage group was higher than that in long-term drainage group ( Z = -2.59, P = 0.009), and there were no statistically significant differences in aspartate aminotransferase (AST), albumin (ALB), total bilirubin (TB) and direct bilirubin (DB) levels between the two groups before biliary drainage (all P > 0.05). After biliary drainage, DB in short-term drainage group was higher than that in long-term drainage group ( Z = -3.34, P = 0.001), and there was no statistically significant difference in ALT, AST, ALB, TB levels between the two groups (all P > 0.05). There were no statistically significant differences in the levels of white blood cells, neutrophils, lymphocytes and the ratio of neutrophils to lymphocytes between the two groups on the 1st and 3rd day after the operation (all P > 0.05). The total incidence of postoperative related complications in short-term drainage group and long-term drainage group was 63.2% (43/68), 70.6% (24/34), respectively, and the difference was statistically significant ( χ2 = 0.54, P = 0.461); the incidences of bile leakage, abdominal or gastrointestinal bleeding, intra-abdominal infection, delayed gastric emptying, all grades of pancreatic leakage, grade B and C pancreatic leakage were not statistically different between the two groups (all P > 0.05); the incidence of severe postoperative related complications in short-term drainage group was higher than that in long-term drainage group [27.9% (19/68) vs. 8.8% (3/34), χ2 = 4.90, P = 0.027]. Multivariate logistic regression analysis showed that the long-term preoperative biliary drainage was an independent protective factor for postoperative severe complications (long-term drainage vs. short-term drainage: OR = 0.253, 95% CI 0.066-0.975, P = 0.046), while BMI ( OR = 1.174, 95% CI 0.986-1.398, P = 0.071) and pathological type (benign or borderline vs. malignant tumor: OR = 0.247, 95% CI 0.043-1.419, P = 0.117) were not independent influencing factors for postoperative severe complications. Conclusions:Short-term biliary drainage (≤14 d) is a risk factor for postoperative severe complications in patients with hepatopancreatic ductal periampullary tumor undergoing preoperative biliary drainage. Preoperative biliary drainage time is not associated with postoperative total complications, pancreatic leakage, bile leakage, abdominal or gastrointestinal bleeding, intra-abdominal infection, delayed gastric emptying.

Progress of diagnosis and treatment for gastrointestinal neuroendocrine neoplasms / 肿瘤研究与临床

Gastrointestinal neuroendocrine neoplasm (GI-NEN) is an important part of digestive system tumor. With the progress of diagnosis and the further understanding of GI-NEN, the diagnostic rate is increasing. However, GI-NEN is a rare tumor, thus clinicians are not familiar with the diagnosis and treatment. Misdiagnosis and missed diagnosis of GI-NEN often occur, and the treatment regimen is not standardized. In recent years, some progresses of the diagnosis and treatment have been made in GI-NEN, especially in the aspects of pathology, imaging diagnosis, radionuclide therapy, targeted therapy and immunotherapy, which have improved the diagnosis rate and efficacy for GI-NEN. This paper reviews recent literatures of GI-NEN, summarizes its epidemiology, pathological diagnosis, image diagnosis, surgery, targeted therapy, radionuclide therapy, chemotherapy, immunotherapy, and separates GI-NEN into metastatic and non-metastatic groups for detailed review to provide a reference for guiding clinical diagnosis and treatment as well as exploring the new treatment regimens of GI-NEN.

Clinicopathological features and prognostic analysis of primary duodenal adenocarcinoma / 中华普通外科杂志

Objective:By analyzing the clinical data of patients with primary duodenal adenocarcinoma (PDA), the risk factors affecting the postoperative prognosis of PDA patients were discussed.Methods:The clinical data of 191 patients diagnosed with PDA in Peking University First Hospital from Jan 2009 to Dec 2022 were collected. The survival rate was calculated and the survival curve was plotted by Kaplan-Meier method. Univariate analysis was performed by Log-Rank test, and multivariate analysis was performed by COX proportional hazards regression model to obtain independent risk factors.Results:The median age of onset in patients with PDA is 65 years old, and the most common symptoms are abdominal pain and abdominal distension. Prognostic analysis showed that the survival rates at 1, 3 and 5 years were 73.8%, 44.6%, and 23.0%. The analysis of Cox risk proportional regression model showed that preoperative CA19-9 level, depth of tumor invasion, degree of differentiation, TNM stage, and surgical mode were independent risk factors for the prognosis of PDA (all P<0.01). Conclusion:The overall incidence of PDA is low, but the prognosis is rather poor. Multvariable factors are associated with its prognosis and surgery is still the mainstay for hope of cure.

Clinical characteristics and prognosis of duodenal neuroendocrine neoplasms / 中华普通外科杂志

Objective:To investigate the clinical characteristics and prognosis of duodenal neuroendocrine neoplasms.Methods:The clinical data of 35 patients with duodenal neuroendocrine neoplasms admitted to Union Hospital, Tongji Medical College, Huazhong University of Science & Technology from Jan 2012 to Dec 2021 were retrospectively analyzed. The differences of clinical characteristics between periampullary and non-periampullary duodenal neuroendocrine neoplasms were analyzed. Kaplan-Meier curve was used for survival analysis, and the clinical factors affecting the prognosis were analyzed.Results:Of the 35 patients, 30 underwent tumor resection, 7 (23%) developed different degree of complications after operation and were improved and discharged after intervention. A total of 5 patients died during the follow-up period. Only 1 of 30 patients who underwent tumor resection died 30 months after operation due to disease progression, and the others had no recurrence or metastasis. Univariate analysis showed that tumor size, tumor grade, and tumor location were associated with the prognosis of patients (all P<0.05), and multivariate analysis showed that patients with tumors located.Away from the ampulla had a significantly better prognosis than those located around the duodenal ampulla ( P<0.01). Conclusions:Patients with duodenal neuroendocrine neoplasms have a good prognosis after complete resection; patients with duodenal neuroendocrine neoplasms located around the ampulla of Vater have a relatively poor prognosis compared with those away from the area of ampulla.

A case of duodenal ulcer as prominent manifestation of IgG4-related disease / 北京大学学报(医学版)

A case of IgG4-related disease presented with a duodenal ulcer to improve the understan-ding of IgG4-related diseases was reported. A 70-year-old male presented with cutaneous pruritus and abdominal pain for four years and blackened stools for two months. Four years ago, the patient went to hospital for cutaneous pruritus and abdominal pain. Serum IgG4 was 3.09 g/L (reference value 0-1.35 g/L), alanine aminotransferase 554 U/L (reference value 9-40 U/L), aspartate aminotransferase 288 U/L (reference value 5-40 U/L), total bilirubin 54.16 μmol/L (reference value 2-21 μmol/L), and direct bilirubin 29.64 μmol/L (reference value 1.7-8.1 μmol/L) were all elevated. The abdominal CT scan and magnetic resonance cholangiopancreatography indicated pancreatic swelling, common bile duct stenosis, and secondary obstructive dilation of the biliary system. The patient was diagnosed with IgG4-related disease and treated with prednisone at 40 mg daily. As jaundice and abdominal pain improved, prednisone was gradually reduced to medication discontinuation. Two months ago, the patient developed melena, whose blood routine test showed severe anemia, and gastrointestinal bleeding was diagnosed. The patient came to the emergency department of Beijing Hospital with no improvement after treatment in other hospitals. Gastroscopy revealed a 1.5 cm firm duodenal bulb ulcer. After treatment with omeprazole, the fecal occult blood was still positive. The PET-CT examination was performed, and it revealed no abnormality in the metabolic activity of the duodenal wall, and no neoplastic lesions were found. IgG4-related disease was considered, and the patient was admitted to the Department of Rheumatology and Immunology of Beijing Hospital for further diagnosis and treatment. The patient had a right submandibular gland mass resection history and diabetes mellitus. After the patient was admitted to the hospital, the blood test was reevaluated. The serum IgG4 was elevated at 5.44 g/L (reference value 0.03-2.01 g/L). Enhanced CT of the abdomen showed that the pancreas was mild swelling and was abnormally strengthened, with intrahepatic and extrahepatic bile duct dilation and soft tissue around the superior mesenteric vessels. We pathologically reevaluated and stained biopsy specimens of duodenal bulbs for IgG and IgG4. Immunohistochemical staining revealed remarkable infiltration of IgG4-positive plasma cells into duodenal tissue, the number of IgG4-positive cells was 20-30 cells per high-powered field, and the ratio of IgG4/IgG-positive plasma cells was more than 40%. The patient was treated with intravenous methylprednisolone at 40 mg daily dosage and cyclophosphamide, and then the duodenal ulcer was healed. IgG4 related disease is an immune-medicated rare disease characterized by chronic inflammation and fibrosis. It is a systemic disease that affects nearly every anatomic site of the body, usually involving multiple organs and diverse clinical manifestations. The digestive system manifestations of IgG4-related disease are mostly acute pancreatitis and cholangitis and rarely manifest as gastrointestinal ulcers. This case confirms that IgG4-related disease can present as a duodenal ulcer and is one of the rare causes of duodenal ulcers.

An unusual case of left para-duodenal hernia as a cause of recurrent intestinal obstruction-managed with laparoscopic approach

Left para-duodenal hernia (PDH) makes for around 40% of all internal hernias. It is due to the prolapse of the bowel through the fossa of Landzert, an anatomic variant that is found in around 2% of the population. This hernia is presumed to be spontaneously reducible in many patients with recurrent symptoms. The present report shows the case of this condition in a 27-year-old female presenting with recurrent abdominal pain and subacute intestinal obstruction who was managed conservatively initially. She has been operated on with a laparoscopic approach. A proper diagnosis with an immediate surgical intervention is necessary for achieving the patient抯 cure and preventing complications in the future. The laparoscopic approach is usually suitable for patients with or without small bowel obstruction and hemodynamically stable.

Síndrome de Bouveret como variante de íleo biliar / Bouveret syndrome as a variant of gallstone ileus

Introducción. El síndrome de Bouveret es una variante del íleo biliar, de rara presentación dentro de las causas de obstrucción intestinal, generada por la impactación de un lito biliar a nivel del duodeno, secundario a la formación de una fístula bilioentérica. Es más común en mujeres en la octava década de la vida, con múltiples comorbilidades. y presenta síntomas inespecíficos, documentándose la triada de Rigler hasta en el 80 % de las tomografías de abdomen. La cirugía sigue siendo el tratamiento de elección. Caso clínico. Presentamos el caso de una paciente de 76 años, con múltiples antecedentes y cuadros previos de cólico biliar, que consultó por dolor abdominal y signos de hemorragia de vías digestivas altas y se documentó un síndrome de Bouveret. Fue tratada en la misma hospitalización mediante extracción quirúrgica del cálculo con posterior resolución de su sintomatología.Conclusión. A pesar de que el síndrome deBouveret es una entidad de infrecuente presentación, los cirujanos generalesdeben estar familiarizados con esta patología, en el contexto del paciente que consulta con un cuadro de obstrucción intestinal, conociendo el valor de la tomografía de abdomen y la endoscopia de vías digestivas altas, teniendo en cuenta la edad y las condiciones del paciente para definir el manejo quirúrgico más adecuado.

Introduction. Bouveret's syndrome is a variant of gallstone ileus, of rare presentation within the causes of intestinal obstruction, generated by the impaction of a biliary stone at the level of the duodenum, secondary to the formation of a biliary-enteric fistula. It is more common in women in the eighth decade of life, with multiple comorbidities, and presents non-specific symptoms, with Rigler's triad being documented in up to 80% of abdominal CT scans. Surgery remains the treatment of choice. Clinical case. We present the case of a 76-year-old patient, with history of multiple episodes of biliary colic, who consulted for abdominal pain and signs of upper gastrointestinal bleeding. Bouveret's syndrome was documented. She was treated in the same hospitalization by surgical extraction of the stone with subsequent resolution of her symptoms. Conclussion. Although Bouveret's syndrome is an entity of infrequent presentation, general surgeons must be familiar with this pathology in the context of the patient who presents with intestinal obstruction, knowing the value of abdominal tomography and upper GI endoscopy, taking into account the age and conditions of the patient to define the most appropriate surgical management.

Tratamiento laparoscópico de úlcera duodenal perforada mediante parche de Graham en un paciente pediátrico / Laparoscopic treatment of perforated duodenal ulcer using a Graham patch in a pediatric patient

Introducción. La úlcera duodenal perforada es una entidad de etiología no clara que rara vez ocurre en la población pediátrica. Generalmente se diagnostica de manera intraoperatoria y el tratamiento ideal incluye el uso del parche de epiplón o de ser necesario, la resección quirúrgica. Caso clínico. Se presenta un paciente de 12 años con abdomen agudo y diagnóstico tomográfico prequirúrgico de úlcera duodenal perforada, tratado por vía laparoscópica con drenaje de peritonitis y parche de Graham. La evolución y el seguimiento posterior fueron adecuados. Discusión. La úlcera duodenal perforada es una entidad multifactorial, en la que se ha implicado el Helicobacter pylori. El diagnóstico preoperatorio es un reto y el tratamiento debe ser quirúrgico. Conclusiones. Cuando se logra establecer el diagnóstico preoperatorio, se puede realizar un abordaje laparoscópico y el uso del parche de Graham cuando las úlceras son menores de dos centímetros.

Introduction. Perforated duodenal ulcer is an entity of unclear etiology that rarely occurs in the pediatric population. It is usually diagnosed intraoperatively and the ideal treatment includes the use of the omentum patch or, if necessary, surgical resection. Clinical case. A 12-year-old patient with acute abdomen and preoperative tomographic diagnosis of perforated duodenal ulcer, treated laparoscopically with peritonitis drainage and Graham patch is presented. The evolution and subsequent follow-up were adequate. Discussion. Perforated duodenal ulcer is a multifactorial entity, in which Helicobacter pylori has been implicated. Preoperative diagnosis is challenging and treatment must be surgical. Conclusions. When the preoperative diagnosis is established, a laparoscopic approach and the use of the Graham patch can be performed when the ulcers are less than two centimeters.