Resección laparoscópica de tumor hepático / Laparoscopic Resection of Hepatic Tumor

Introducción: La cirugía laparoscópica desde su introducción en 1987 ha experimentado un enorme desarrollo. La cirugía hepática laparoscópica de los tumores hepáticos plantea diversas controversias: los cirujanos deben estar formados en cirugía hepática y cirugía laparoscópica, la técnica laparoscópica más adecuada no está bien definida (totalmente laparoscópica o asistida con la mano), el abordaje o disección de grandes vasos entraña riesgos importantes, los métodos de sección parenquimatosa están menos desarrollados que en la cirugía hepática abierta entre otros retos. A pesar de estos criterios existen situaciones en que la cirugía puede llevarse a cabo con seguridad, sobre todo en tumores benignos y malignos cuando las lesiones se localizan principalmente en segmentos anteriores del hígado. Objetivo: Presentar una paciente portadora de una lesión hepática intervenida quirúrgicamente por videolaparoscopía con buenos resultados y evolución excelente. Caso clínico: Paciente femenina de 42 años de edad; antecedentes de salud con presencia de dolor abdominal de tres meses de evolución en región de hipocondrio derecho y trastornos dispépticos esporádicos. Se confirmó imaginológicamente un tumor de 5 cm de diámetro en segmento III, de aspecto hemangiomatoso con componente mixto y sospecha de malignidad. Se realizó resección laparoscópica, el diagnóstico anatomopatológico fue nódulo regenerativo, tipo nódulo cirrótico con hemangioma cavernoso de localización periférica en hígado sano, sin evidencias de malignidad en los estudios realizados. Conclusiones: Las resecciones quirúrgicas de lesiones hepáticas abordables por vía laparoscópica son una opción terapéutica segura y muy válida en pacientes con indicaciones específicas(AU)

Introduction: Laparoscopic surgery, since its introduction in 1987, has undergone enormous development. Laparoscopic hepatic surgery of liver tumors raises several controversies: surgeons must be trained in hepatic surgery and laparoscopic surgery, the most appropriate laparoscopic technique is not well defined (totally laparoscopic or hand-assisted), the approach to or dissection of large vessels involves significant risks, the methods for parenchymal section are less developed than in open hepatic surgery, among other challenges. Despite these criterions, there are situations in which the surgery can be performed safely, above all in benign and malignant tumors when the lesions are located mainly in anterior segments of the liver. Objective: To present the case of a patient with a hepatic lesion and operated on by videolaparoscopy with good outcomes and excellent evolution. Clinical case: A 42-year-old female patient with a family history of disease presented abdominal pain of three months of evolution in the right hypochondrium and sporadic dyspeptic disorders. Imaging confirmed a tumor of 5 cm of diameter in segment III, with hemangiomatous aspect, mixed component and suspicion of malignancy. Laparoscopic resection was performed; the anatomopathological diagnosis was regenerative nodule, similar to a cirrhotic nodule with cavernous hemangioma of peripheral location in healthy liver, with no evidence of malignancy in the performed studies. Conclusions: Surgical resections of hepatic lesions that can be laparoscopically approached are a safe and very valid therapeutic option in patients with specific indications(AU)

Hemiparkinsonism associated with mesencephalic cavernoma: case report and review of literature

Parkinsonism is a movement disorder characterized by resting tremor, slow and decreased movements (hypokinesia and akinesia), rigidity, postural instability, problems with gait, and coordination. Parkinson?s disease (PD) is the most common cause of parkinsonism and its prevalence is estimated to range from 0.1 per cent to 0.3 per cent in the general population and from 1 per cent to 2 per cent in persons 65 years of age or older. Although the majority of cases of PD are describe to be sporadic, many identifiable etiologies have been included as possible causes of parkinsonism, such as genetic disorders, cerebrovascular events and intoxication. However, mesencephalic cavernoma is an extremely rare condition associated to hemiparkinsonism. In the present report, we describe the case of a Brazilian woman that evolved symptoms of hemiparkinsonism and presented a ventral mesencephalic cavernoma on radiological investigation.

O parkinsonismo corresponde a um transtorno do movimento caracterizado por tremores de repouso, redução e lentidão dos movimentos (hipocinesia e acinesia), rigidez, instabilidade postural e problemas relacionados a marcha e coordenação. A doença de Parkinson (DP) é a causa mais comum de parkinsonismo e sua prevalência é estimada em torno de 0,1 por cento a 0,3 por cento em relação à população geral e 1 por cento a 2 por cento em pessoas acima de 65 anos de idade. Embora a maioria dos casos de DP tenha sido descrita como casos esporádicos, muitas etiologias identificáveis foram incluídas como possíveis causas de parkinsonismo, tais como alterações genéticas, eventos cerebrovasculares e intoxicações. No entanto, o cavernoma mesencefálico é uma causa de hemiparkinsonismo extremamente rara. No presente relato, descreve-se o caso de uma mulher brasileira que apresentou sintomas de hemiparkinsonismo relacionados à presença de um cavernoma mesencefálico ventral na investigação radiológica.

Giant cavernous hemangioma of the cavernous sinus: case report and review of literature

The incidence of cavernous sinuses cavernous hemangiomas is 2 percent of all cavernous malformations. These lesions are well circumscribed benign neoplasm, that are confined to the dural layer of the venous sinus. These lesions are difficult to accurately diagnose them presurgically and the surgical treatment is also difficult. Nevertheless with the new imagining diagnosis technologies and with advancement in microneurosurgical techniques, neurosurgeons can treat these lesions with more confidence. In this article we want to report a case of a 24 year woman who presented to our institution with galactorrea as the only clinical presentation. This patient was investigated and was found to have a giant lesion in the right middle fossa. She was taken to surgery with the suspicion of a giant meningioma but this surgery was aborted when we found that the lesion did not correspond to a meningioma. The patient was followed for 4 years and the galactorrea was treated and she was stable, but then she presented with severe headache and deterioration in her consciousness. She was treated in another institution where she was taken to surgery and a partial resection was performed, the surgery was aborted because the patient presented massive bleeding. we want to present this case that is dealing with an infrequent lesion of a very delicate localization of the skull base. We also want to emphasize in having this differential diagnosis when dealing with lesions in this area. We also want to warn and recommend that if a neurosurgeon stumble into one of these lesions in surgery we recommend to back off and plan better the surgical management. Planning adequately the surgical procedure improve the prognosis in these patients We will present this case and review the literature concerning these rare lesions.

La incidencia de los hemangiomas cavernosos del seno cavernoso es del 2 por ciento de todas las malformaciones cavernosas. Estas lesiones son neoplasias benignas bien diferenciadas, que se encuentran confinadas en la capa dural de los senos venosos. Estas lesiones son difíciles de diagnosticar de manera segura en las etapas prequirugicas y su tratamiento es difícil. Sin embargo con las nuevas tecnologías de imágenes diagnosticas y los avances en la microneurocirugía, los neurocirujanos podemos tratar estas malformaciones de manera más segura. En este artículo queremos reportar un caso de una mujer de 24 años quien consulto a nuestra institución por galactorrea. Esta paciente fue investigada y se le diagnostico una lesión gigante de la fosa media derecha. Se llevo a cirugía bajo la sospecha que presentaba un meningioma gigante pero esta cirugía se aborto cuando se encontró que la lesión se trataba de una patología distinta. La paciente siguió en controles por 4 años donde se mantuvo estable con mejoría de la galactorrea con manejo medico, pero luego comenzó a presentar cefalea severa asociada a deterioro de la conciencia. La paciente fue tratada en otra institución donde fue llevada a cirugía en la cual una resección parcial se le realiza a la paciente. Esta cirugía se aborto por un sangrado excesivo. Queremos presentar este caso que trata de una lesión infrecuente en un sitio de alto riesgo quirúrgico de la base del cráneo. Enfatizamos en tener esta patología entre lo diagnósticos diferenciales de las lesiones de esta localización. Además, recomendar que en caso que uno se encuentre con una de estas lesiones en cirugía, recomendamos que finalice la cirugía en ese momento y que planee un manejo quirúrgico enfocado para esta patología en un nuevo tiempo quirúrgico. Un adecuado planeamiento del procedimiento quirúrgico mejora el pronóstico en estos enfermos. En este artículo queremos reportar un caso y revisar la literatura que concierne estas lesiones raras...

Cavernoma de hipocampo associado a epilepsia do lobo temporal refratária / Hippocampal cavernoma associated to refractory temporal lobe epilepsy

Os cavernomas, entre todas as malformações vasculares encontradas no sistema nervoso, constituem os principais causadores de epilepsia. Para ilustrar essa associação, é apresentado o caso de uma paciente com crises convulsivas de início recente, refratárias ao tratamento clínico, ocasionadas por um cavernoma localizado no lobo temporal (hipocampo) direito. A paciente foi submetida a lesionectomia, sem ressecção do córtex temporal adjacente, com resultado pós-operatório positivo. São discutidas as indicações de lesionectomia em indivíduos com epilepsia, com ênfase nos cavernomas, bem como as indicações de corticectomia para o controle das crises e a obtenção de prognóstico favorável.

The cavernomas, of all the vascular malformations found in the nervous system, are the leading cause of epilepsy. To illustrate this association we present the case of a female patient with convulsive crises of recent onset, refractory to clinical treatment, caused by a cavernoma located in the right temporal lobe (hippocampus). The patient was submitted to lesionectomy, without resection of the adjacent temporal cortex, with a positive postoperative outcome. Indications of lesionectomy to individuals with epilepsy are discussed, with an emphasis on cavernomas, as well as indications of corticectomy for the control of crises and the achievement of a favorable prognosis.

Transformación cavernomatosa de la vena porta / Cavernous transformation of the portal vein

Se presenta un caso clínico de transformación cavernomatosa de la vena porta, en una paciente de 37 años que debuta con una hemorragia digestiva alta de muy difícil manejo. Se efectúa el diagnóstico mediante una arteriografía selectiva por sustracción digital. Se interviene quirúrgicamente en reiteradas ocasiones realizándose finalmente una derivación mesocava con prótesis de PTFE. Evoluciona con múltiples complicaciones médicas y quirúrgicas, que finalmente la llevan a la falla multisistémica y posterior fallecimiento. En la autopsia se confirma el diagnóstico de cavernomatosis portal.

Profile of extrahepatic portal venous obstruction in Mumbai.

AIM OF THE STUDY: To study the clinical profile of extrahepatic portal venous obstruction (EHPVO) in a tertiary referral centre in Mumbai. METHODOLOGY: Retrospective analysis of records of 113 patients with EHPVO, treated between January 1984 and May 1996. RESULTS: Thirty eight of 54 (70.4%) patients in whom information was available were delivered at home. Eleven of the 50 (22%) had umbilical sepsis after birth. Median disease duration was 5 years (range 4 months-31 years), with age at initial presentation 13 (range 0.5-45) years; 24 (20%) patients presented after age 20 years. Eleven presenting initially with splenomegaly bled after 3 (1-14) years. Number of bleeding episodes per patient was 2.5 (1-12). 13 of 44 (29.6%) patients bled (first bleed or recurrence) after age 20 years. Twenty five (22.3%) had ascites at some time, 17/102 (16.7%) had hypersplenism, and hypoalbuminaemia was present in 20/103 (19.2%). Endoscopic sclerotherapy obliterated varices in 47/52 (90.4%) in 10.5 (3-40) sessions over 7 (1-100) months. Twenty three patients underwent surgery: devascularisation in 20 (with splenectomy in seven), distal lieno-renal shunt in two, and meso-caval shunt in one patient. Follow-up was available in 68 (60.2%) patients. Rebleeding after sclerotherapy occurred in 27/64 (42.2%), with median one (1-5) per patient; recurrence of varices was noted in 15/35 (42.9%) patients over 12 (3-39) months. Varices were present in 12 patients 163 (33-305) months after surgery. CONCLUSIONS: Home delivery and umbilical sepsis may be risk factors in the development of EHPVO. A significant number of patients present or continue to bleed from varices after age 20. Variceal sclerotherapy is effective for eradication of oesophageal varices.