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.

Divertículo duodenal intraluminal como causa de obstrucción duodenal / Intraluminal duodenal diverticulum as a cause of duodenal obstruction

Introducción. El divertículo duodenal intraluminal, también conocido como windsock diverticulum, es una causa rara de dolor abdominal intermitente y plenitud postpandrial, que puede complicarse con obstrucción, sangrado, pancreatitis o colangitis. Suele cursar de forma asintomática y ante la aparición de síntomas el tratamiento de elección es quirúrgico. Caso clínico. Presentamos el caso de una mujer de 24 años, sin antecedentes de interés, que es estudiada por dolor abdominal y plenitud postpandrial, que resulta finalmente en una obstrucción intestinal alta. Tras estudio exhaustivo y necesidad de una cirugía previa, es diagnosticada de un divertículo duodenal intraluminal. Conclusión. La paciente se trató mediante cirugía con resolución exitosa del cuadro de obstrucción intestinal.

Introduction: Intraluminal duodenal diverticulum, also known as a windsock diverticulum, is a rare cause of intermittent abdominal pain and postprandial fullness, which can be complicated by obstruction, bleeding, pancreatitis, or cholangitis. It is usually asymptomatic and when symptoms appear, the treatment of choice is surgical. Clinical case: We present the case of a 24-year-old woman with no relevant history who is studied for abdominal pain and postprandial fullness, presented with an upper intestinal obstruction. After an exhaustive study and the need for a previous surgery, she was diagnosed with an intraluminal duodenal diverticulum.Conclusion: The patient was treated by surgery with successful resolution of the intestinal obstruction

Duodenoyeyunostomía laparoscópica en el Síndrome de la Arteria Mesentérica Superior / Laparoscopic duodenojejunostomy for Superior Mesenteric Artery Syndrome

Introducción: El Síndrome de la Arteria Mesentérica Superior es causa poco frecuente de obstrucción duodenal. Los síntomas varían desde una obstrucción leve hasta emergencias agudas. El examen físico no siempre ayuda al diagnóstico, que se basa en los hallazgos imagenológicos. Objetivo: preconizar, recomendar el uso de las técnicas mínimamente invasivas en el manejo quirúrgico del Síndrome de la Arteria Mesentérica Superior. Presentación del caso: Mujer de 49 años de edad, antecedentes de pérdida de peso después de quimioterapia con náuseas, vómitos y dolor abdominal posprandial de dos años de evolución. Tratada exitosamente con duodenoyeyunostomía laparoscópica. El tratamiento inicial suele ser conservador. Publicaciones recientes respaldan que la duodenoyeyunostomía laparoscópica es un método seguro y efectivo para su tratamiento. Conclusiones: El tratamiento quirúrgico es cada vez más exitoso, la mayoría de los pacientes no presenta síntomas después de la cirugía(AU)

Introduction: Superior Mesenteric Artery Syndrome is an uncommon cause of duodenal obstruction. Symptoms may vary from mild obstruction to acute life-threatening emergencies. Physical examination does not always help in establishing the diagnosis which is based on findings from imaging studies. Objective: To recommend the laparoscopic approach for the surgical treatment of this entity. Case presentation: A 49-year old female patient with prior history of weight loss after chemotherapy and a two-year history of postprandial nausea, vomiting, and abdominal pain who was successfully treated by laparoscopic duodenojejunostomy is presented. Discussion: Initial treatment is usually conservative. Recently published studies support that laparoscopic duodenojejunostomy is a safe and effective method of treatment. Conclusions: Surgical treatment is becoming more successful and the majority of patients are symptom-free after surgery(AU)

Tratamiento quirúrgico paliativo de los tumores periampulares, una opción de paliación a largo plazo / Palliative surgical treatment of periampullary tumors, an option of long-term palliation

RESUMEN Introducción: los tumores de la encrucijada duodeno-bilio-pancreática o periampulares corresponden a un grupo heterogéneo de tumores. Se originan dentro de los 2 cm de la papila duodenal mayor. En los tumores irresecables, el tratamiento debe estar dirigido a la paliación más efectiva. El tratamiento quirúrgico paliativo va dirigido a resolver la obstrucción biliar, duodenal y el dolor, con el fin de optimizar la calidad de vida de los pacientes. Objetivo: describir el comportamiento del tratamiento quirúrgico paliativo de los tumores periampulares. Materiales y métodos: se realizó una investigación observacional, descriptiva y prospectiva con los pacientes con tumor periampular irresecable tributarios a tratamiento quirúrgico paliativo, en el Servicio de Cirugía General del Hospital Universitario "Comandante Faustino Pérez Hernández", en la ciudad de Matanzas, desde enero del 2010 hasta diciembre del 2019. Resultados: el tumor de páncreas fue el más representado. Todos los pacientes fueron tributarios de derivación biliar quirúrgica paliativa, sin embargo, la derivación gástrica se realizó solo con confirmación endoscópica de infiltración tumoral u obstrucción duodenal y la esplacnicectomía química, siempre que fue factible técnicamente o las condiciones del paciente lo permitieron. La hepaticoyeyunostomía en Y de ROUX fue la derivación biliar de elección. La principal complicación quirúrgica fue la sepsis provocando las muertes. Conclusiones: la paliación quirúrgica es la alternativa de elección con mejores resultados a largo plazo, en los tumores periampulares irresecables con buen estado general, lo que contribuye a una mejor calidad de vida (AU).

ABSTRACT Introduction: the tumors of the duodenal-biliary-pancreatic junction or periampullary tumors correspond to a heterogeneous group of tumor. They originate inside the 2 cm of the major duodenal papilla. In unresectable tumors, the treatment should be intended for the most effective palliation. The surgical palliative treatment is intended for solving biliary, duodenal obstruction, and pain, with the aim of optimizing patients' life quality. Objective: to describe the behavior of the periampullary tumors palliative surgical treatment. Materials and methods: a prospective, descriptive, observational research was carried out in patients with unresectable periampullary tumor tributary to palliative surgical treatment, in the Service of General Surgery of the University Hospital "Comandante Faustino Perez Hernandez", of Matanzas, from January 2010 to December 2019. Results: pancreas tumor was the most represented one. All patients were tributary to biliary palliative surgical derivation, however, gastric derivation was performed only with endoscopic confirmation of tumor infiltration or duodenal obstruction, and chemical splanchnicectomy whenever it was technically feasible and the patient's conditions allowed it. Roux's Y-shaped hepaticojejunostomy was the elective biliary derivation. The main surgical complication was sepsis provoking deaths. Conclusions: surgical palliation is the election alternative with long- term better outcomes, in unresectable periampullary tumors with a good general status, contributing to better life quality (AU).

Value of chromosomal microarray analysis for fetuses with duodenal obstruction / 中华医学遗传学杂志

OBJECTIVE@#To assess the value of chromosomal microarray analysis (CMA) for fetal duodenal obstruction (DO).@*METHODS@#Fifty-one fetuses with DO identified by prenatal ultrasound were divided into DO only group and DO with other anomaly group. CMA was carried out on amniotic fluid or umbilical blood samples, and the outcome of pregnancy of all cases were followed up.@*RESULTS@#Eight fetuses (15.7%) were found with genomic abnormalities, which included 3 chromosomal aneuploidies and 5 copy number variations (CNVs), including one 17q12 microduplication syndrome, one 13q21.33q31.1 microdeletion, one 13q21.32q22.3 deletion, one 13q21.2q31.1 deletion and one 1q43q44 duplication. EDNRB from 13q and HNF1B from 17q12 are candidate genes for fetal DO. No significant difference was found in the detection rate of pathogenic CNVs between the DO only and DO with other anomaly groups (9.5% vs.11.1%, P> 0.05). There were 39 live borns, 1 stillbirth, and 11 artificial abortions (8 with abnormal CMA results).@*CONCLUSION@#There is a correlation between fetal DO and abnormal copy number of the genome, for which prenatal diagnosis is necessary. CMA not only can detect microdeletions/microduplications, but also identify pathogenic genes, which can facilitate prenatal diagnosis, genetic counseling and prognosis for the fetus.

Duodenal Leiomyosarcoma Presenting with Gastrointestinal Bleeding and Obstruction: A Case Report / 대한소화기학회지

Duodenal leiomyosarcoma is a rare condition with a poor prognosis. Early diagnosis of duodenal leiomyosarcoma is challenging because it presents with nonspecific symptoms and endoscopic biopsies usually do not enable a definitive diagnosis. Duodenal leiomyosarcomas are diagnosed on the basis of the histopathological identification of a mesenchymal lesion composed of malignant tumor cells that on immunohistochemical examination is positive for smooth muscle actin and desmin. We report the case of a 38-year-old man who presented with gastrointestinal bleeding and obstruction who was diagnosed with duodenal leiomyosarcoma after surgical resection.

Obstrucción duodenal congénita de etiología múltiple: reporte de un caso con malrotación intestinal, bandas de Ladd y membrana duodenal intrínseca como causantes de obstrucción intestinal en el neonato / Congenital duodenal obstruction of multiple etiology: case report with intestinal malrotation, Ladd bands and intrinsic duodenal membrane as causes of intestinal obstruction in the neonate

Resumen: La obstrucción duodenal congénita agrupa un amplio espectro de anomalías en el desarrollo del intestino delgado; se clasifica según su etiología tanto en extrínseca como intrínseca. Su presentación es relativamente común, teniendo una incidencia de 1: 2.500-10.000 nacidos vivos y normalmente presenta asociación con aneuploidías (como la trisomía 21) y malformaciones cardíacas. Las imágenes tienen un papel importante en la aproximación diagnóstica y la radiografía de abdomen simple, es el primer escalón en la aproximación de la obstrucción intestinal. El tratamiento involucra una exploración quirúrgica del abdomen con corrección de los defectos encontrados. Este es un reporte de caso de un neonato que presentó obstrucción duodenal congénita de etiología tanto extrínseca (malrotacion intestinal y bandas de Ladd) como obstrucción intrínseca (membranas duodenales).

Abstract: Congenital duodenal obstruction groups together a broad spectrum of abnormalities in the development of the small intestine; it is classified according to its etiology as both extrinsic and intrinsic. Its presentation is relatively common, having an incidence of 1: 2.500-10.000 live births and it is normally associated with aneuploidy (such as trisomy 21) and cardiac malformations. Images play an important role in the diagnostic approach, with simple abdominal radiography being the first step in the approximation of intestinal obstruction. The treatment corresponds to a surgical exploration of the abdomen with resolution of the defects found. This is a case report of a newborn who presented congenital duodenal obstruction of both extrinsic etiology (intestinal malrotation and Ladd bands) and intrinsic obstruction (duodenal membranes).

Síndrome de Bouveret, una causa extraña de obstrucción intestinal alta: reporte de caso / Case report of Bouveret syndrome: a strange cause of upper intestinal obstruction

Resumen El síndrome de Bouveret (SB) es una patología poco frecuente, la cual se caracteriza por la presencia de obstrucción gástrica o duodenal secundaria a un cálculo enclavado en la luz duodenal, el cual migra a través de una fístula colecistoduodenal. Su incidencia es de alrededor 1% al 3% de todos los casos de íleo biliar. Los principales síntomas consisten en vómito, dolor abdominal, hematemesis, pérdida de peso y anorexia. En el 91% de los casos se requiere manejo quirúrgico. En este artículo se presenta un caso de un paciente de 50 años, con cuadro clínico de 2 meses de evolución de dolor abdominal en epigastrio y mesogastrio, distensión abdominal y múltiples episodios de emesis. Al examen físico con clínica de obstrucción intestinal se realizó tomografía abdominal, donde se evidenció obstrucción intestinal por imagen intraluminal en primera porción duodenal asociada con tríada de Rigler, con diagnóstico de síndrome de Bouveret.

Abstract Bouveret syndrome is a rare pathology which is characterized by gastric or duodenal obstruction secondary to a gallstone embedded in the lumen after migrating through a cholecystoduodenal fistula. Its incidence is approximately 1% to 3% of all cases of biliary ileus. The main symptoms consist of vomiting, abdominal pain, hematemesis, weight loss and anorexia. Surgery is required in 91% of cases. This article presents the case of a 50-year-old patient who had suffered from abdominal pain in the epigastrium and mesogastrium, abdominal distension and multiple episodes of emesis for two months. Physical examination indicated obstruction of the intestine. An abdominal CT scan showed that the obstruction was in the first duodenal portion and that Rigler's triad was present. It was diagnosed as Bouveret Syndrome.

Síndrome de la arteria mesentérica superior en una adolescente de 12 años. Caso clínico / Superior mesenteric artery syndrome in a 12-year-old adolescent. Clinical case

El síndrome de la arteria mesentérica superior es una enfermedad poco frecuente en pediatría. Se produce por la compresión de la tercera porción duodenal a su paso entre la arteria mesentérica superior y la aorta abdominal (compás aortomesentérico). La mayoría de los pacientes presentan factores predisponentes:pérdida de peso aguda o compresiones extraabdominales.Se presenta el caso de una niña de 12 años de edad a quien se le diagnosticó el síndrome sin presentar factores predisponentes.Comenzó de modo súbito con náuseas, vómitos incoercibles y dolor abdominal, que era posprandial y se aliviaba, llamativamente, en decúbito lateral izquierdo. Esto constituyó la sospecha clínica del síndrome, por lo que se solicitó una angio tomografía computada abdominal y se observó el estrechamiento del compás aortomesentérico. Se realizó un tratamiento médico conservador, sin respuesta clínica. Se decidió el tratamiento quirúrgico y se logró la resolución del cuadro clínico

The superior mesenteric artery syndrome is rarely seen in children. It results from an intestinal obstruction due to compression of the third portion of duodenum between the superior mesenteric artery and the abdominal aorta. In most of the cases there are predisposing factors such as rapid weight loss or extra-abdominal compression.We report a case of a superior mesenteric artery syndrome in a twelve-year-old female patient without predisposing factors. The girl began suddenly with nauseas, continuous vomiting and abdominal pain. The abdominal pain was postprandial and it decreased in left lateral decubitus position. Clinically, this characteristic suggested superior mesenteric artery syndrome. Angio-computed tomography scan confirmed the diagnosis. Given that conservative treatment ultimately failed, patient was subjected to surgery and the illness was resolved.

Obstrucción duodenal y hemorragia digestiva alta como presentación inicial de una tuberculosis duodenal aislada / Duodenal obstruction and upper gastrointestinal bleeding as the initial presentation of an isolated duodenal tuberculosis

Resumen La tuberculosis duodenal primaria es muy infrecuente, incluso en regiones endémicas. El diagnóstico plantea un gran reto, y requiere un alto índice de sospecha, apoyado en estudios de imágenes, microbiología, e histopatología obtenida por biopsia endoscópica o quirúrgica. Presentamos el caso de un varón de 31 años, sin infección por VIH ni antecedente de tuberculosis, que debutó con una obstrucción duodenal. Posterior a una laparatomía exploradora presentó una estenosis duodenal y una hemorragia digestiva alta. Luego de varias biopsias no concluyentes, sólo la última, realizada con la técnica "biopsia sobre biopsia", demostró la presencia de granulomas con bacilos ácido-alcohol resistentes. El diagnóstico de tuberculosis fue confirmado por reacción de polimerasa en cadena de tejido duodenal. No se evidenció compromiso de otros órganos. La respuesta terapéutica fue excelente.

Primary duodenal tuberculosis is rare, even in endemic regions. The diagnosis poses a major challenge and requires a high index of suspicion, supported by imaging studies, microbiology, and histopatology obtained by endoscopic or surgical biopsy. We report the case of a 31-year-old man, without HIV infection or any previous history of tuberculosis, who presented with duodenal obstruction. After exploratory laparotomy, he presented a duodenal stenosis and upper gastrointestinal bleeding. A total of four diagnostic procedures (one laparotomy and three endoscopies) were performed, all of which included biopsies. Only the last endoscopy made with the technique "biopsy upon biopsy" showed the presence of acid fast bacilli and granulomas. The diagnosis of tuberculosis was confirmed by polymerase chain reaction in duodenal tissue. There was no evidence of involvement of other organs by tuberculosis. The patient had an excellent therapeutic response.

Obstrucción duodenal por Strongyloides stercoralis, una complicación inusual / Duodenal obstruction by Strongyloides stercoralis, an unusual complication

Resumen La estrongiloidiasis es una enfermedad desatendida en Latinoamérica. Las manifestaciones gastrointestinales son inespecíficas y la obstrucción duodenal es una complicación infrecuente. Presentamos el caso clínico de un varón de 31 años, procedente de la selva central de Perú, que ingresó por una obstrucción intestinal alta, con úlceras y una estenosis duodenal evidenciadas en la endoscopia digestiva alta. El informe histopatológico reveló la presencia de larvas de Strongyloides stercoralis. La evolución clínica y endoscópica fueron favorables con el tratamiento con ivermectina. Existen poco más de 20 casos publicados de obstrucción duodenal por S. stercoralis. Adicionalmente, se confirmó una infección por HTLV-1, asociación descrita frecuente.

Strongyloidiasis is a neglected disease in Latin America. Gastrointestinal manifestations are nonspecific and duodenal obstruction is a rare complication. Here we present the case of a 31-year-old male from the central jungle of Peru, admitted due to a high intestinal obstruction, with duodenal ulcers and stenosis evidenced in the upper endoscopy. The histopathological report revealed presence of larvae of Strongyloides stercoralis. Clinical and endoscopic follow up were favorable with ivermectin treatment. There are near 20 reported cases of duodenal obstruction due to S. stercoralis. Additionally, infection by HTLV-1 was confirmed, being this a frequent association.

Obstrucción duodenal debido a páncreas anular en etapa neonatal / Duodenal obstruction due to annular pancreas during the neonatal period / Obstrução duodenal por pâncreas anular no estágio neonatal

Introducción. El páncreas anular es una infrecuente anomalía congénita caracterizada por un anillo de tejido pancreático rodeando la porción descendente del duodeno, representa el 1 % de las obstrucciones intestinales neonatales a nivel mundial. El diagnóstico y tratamiento definitivo es quirúrgico. El objetivo es describir un caso clínico neonatal con páncreas anular, abordando una revisión reducida de la literatura en su diagnóstico, evolución y tratamiento. Reporte de Caso. Paciente femenina de 24 días de vida con episodios eméticos desde el segundo día de vida, asociado a pérdida de peso e inestabilidad hidroelectrolítica, quien ingresa a la unidad de cuidados intensivos neonatal para manejo. Dada persistencia de sintomatología gastrointestinal e inestabilidad hemodinámica, a pesar de manejo instaurado y ante la alta sospecha de obstrucción intestinal, se procede a realizar examen radiológico de vías digestivas altas con medio de contraste, donde se evidencia signos de estenosis duodenal. Se realiza laparotomía con evidencia de dilatación de segunda y tercera porción del duodeno, paredes engrosadas, cruzado por segmento de páncreas que ocluye su luz totalmente, que corresponde a páncreas anular. Discusión. Tener presente esta entidad dentro de los diagnósticos diferenciales de las obstrucciones duodenales dado que la sintomatología, así como se evidencia en la paciente cambia según el tipo de obstrucción; es necesario solicitar métodos imagenológicos para evaluar signos radiológicos, a fin de esclarecer el diagnóstico y evitar retrasos en el diagnóstico definitivo de páncreas anular, que se realiza por intervención quirúrgica. Conclusión. El páncreas anular sigue siendo un reto diagnóstico dada su infrecuencia. Además, cursa con sintomatología variable e inespecífica, siendo más frecuente el vómito, como fue evidenciado en el caso como el síntoma inicial. Conocer la patología obstructiva duodenal es importante, ya que se encuentra dentro de los diagnósticos diferenciales, ayudando así a evitar retrasos en el abordaje quirúrgico y diagnóstico. Cómo citar: Ortiz-Hernández YV, Ferreira-Traslaviña HH, Duarte-Vergara LM, Africano-León ML. Obstrucción duodenal debido a páncreas anular en etapa neonatal. MedUNAB. 2019;22(1):79-87. doi. org/10.29375/01237047.3423

Introduction. Annular pancreas is an infrequent birth defect characterized by a ring of pancreatic tissue that surrounds the descending part of the duodenum. It accounts for 1 % of neonatal intestinal obstructions worldwide. Diagnosis and final treatment is surgical. The objective is to describe a neonatal clinical case with annual páncreas based on a brief literature review on its diagnosis, evolution and treatment. Case Report. Female patient, 24 days old with emetic episodes starting on the second day of life, associated with loss of weight and hydroelectrolytic instability, who was admitted to the neonatal intensive care unit for management purposes. Given the persistence of the gastrointestinal symptoms and hemodynamic instability, despite the treatment in place, and high level of suspicion of intestinal obstruction, radiology exam of upper digestive tract was performed with contrast medium, finding evidence of signs of duodenal stenosis. Laparotomy was performed, finding evidence of dilation of the second and third parts of the duodenum, thickened walls, crossed by a páncreas segment that fully occludes the light, consistent with annual pancreas. Discussion. Take the above into consideration during differential diagnoses of duodenal obstructions, given that the patient's symptoms, as evidenced in the patient, change depending on the type of obstruction. Imaging methods must be requested to assess radiological signs, in order to clarify the diagnosis and prevent delays in the final diagnosis of annual pancreas, which is performed by means of surgical intervention. Conclusions. Annual pancreas continues to be a diagnostic challenge due to its infrequency. People suffering from this, experience variable and non-specific symptoms; more frequently vomiting, which, in this specific case, was the initial symptom. It is important to learn about the obstructive duodenal pathology, because it is one of the differential diagnoses, and thereby prevents delays in the surgical and diagnostic approach. Cómo citar: Ortiz-Hernández YV, Ferreira-Traslaviña HH, Duarte-Vergara LM, Africano-León ML. Obstrucción duodenal debido a páncreas anular en etapa neonatal. MedUNAB. 2019;22(1):79-87. doi. org/10.29375/01237047.3423

Introdução. O pâncreas anular é uma anomalia congênita rara, caracterizada por um anel de tecido pancreático em torno da porção descendente do duodeno; representa 1 % das obstruções intestinais neonatais em todo o mundo. O diagnóstico e tratamento definitivo é cirúrgico. O objetivo é descrever um caso clínico neonatal com páncreas anular, a partir da revisão reduzida da literatura em seu diagnóstico, evolução e tratamento. Apresentação do caso. Paciente do sexo feminino, 24 dias de vida, com episódios eméticos a partir do segundo dia de vida, associada à perda de peso e distúrbio hidroeletrolítico, que ingressa na unidade de terapia intensiva neonatal para tratamento. Dada a persistência de sintomas gastrointestinais e instabilidade hemodinâmica, a pesar do tratamento estabelecido e da alta suspeita de obstrução intestinal, é realizado exame radiológico do trato digestivo superior com meio de contraste, onde há evidencias de estenose duodenal. É realizada uma laparotomia com evidência de dilatação da segunda e terceira porção do duodeno, paredes espessadas, cruzadas por segmento de pâncreas que oclua completamente sua luz, que corresponde ao pâncreas anular. Discussão. Considerar essa entidade nos diagnósticos diferenciais de obstruções duodenais, uma vez que a sintomatologia, como evidenciado no paciente, muda de acordo com o tipo de obstrução; é necessário solicitar métodos de imagem para avaliar os sinais radiológicos, a fim de esclarecer o diagnóstico e evitar atrasos no diagnóstico definitivo do pâncreas anular que é realizado por meio de intervenção cirúrgica. Conclusões. O pâncreas anular continua a ser um desafio diagnóstico, dada a sua raridade. Além disso, apresenta-se com sintomatologia variável e inespecífica, sendo mais frequente o vômito, que foi evidenciado no caso aqui apresentado, como síntoma inicial. Conhecer a patologia obstrutiva duodenal é importante, pois está dentro dos diagnósticos diferenciais e, assim, ajuda a evitar atrasos na abordagem cirúrgica e no diagnóstico. Cómo citar: Ortiz-Hernández YV, Ferreira-Traslaviña HH, Duarte-Vergara LM, Africano-León ML. Obstrucción duodenal debido a páncreas anular en etapa neonatal. MedUNAB. 2019;22(1):79-87. doi. org/10.29375/01237047.3423

Recurrent Pancreatitis Caused by Afferent Loop Syndrome with Pathologic Features of Type II Autoimmune Pancreatitis / 대한내과학회지

Afferent loop syndrome (ALS) is a rare cause of recurrent pancreatitis. Recurrent pancreatitis in association with ALS can develop due to impaired outflow of pancreatic juice or reflux of enteric secretions caused by increased intraluminal duodenal pressure. Here, we report a case of ALS presenting as recurrent acute pancreatitis due to chronic intermittent partial obstruction of the third portion of the duodenum caused by postoperative adhesion. Interestingly, pancreatic histology showed a granulocytic epithelial lesion, which is a diagnostic feature of type 2 autoimmune pancreatitis (AIP, idiopathic duct centric chronic pancreatitis [IDCP]). From this case we learned that the diagnosis of type 2 AIP should be made in the appropriate clinical setting.

Endoscopic Management of Combined Biliary and Duodenal Obstruction

Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.

Clinical analysis of annular pancreas in neonates / 浙江大学学报·医学版

OBJECTIVE@#To analyze clinical manifestations, diagnosis and treatment of annular pancreas in neonates.@*METHODS@#Clinical data of 114 neonates with annular pancreas admitted in the Children's Hospital of Zhejiang University from January 2009 to December 2018 were reviewed. The demographic parameters (gestational age, birth weight), clinical manifestations, onset time, results of antenatal examination, associated anomalies, radiological findings, operations, postoperative complications were analyzed.@*RESULTS@#One hundred and two cases were examined by abdominal echography, in which 68 cases showed duodenal obstruction, 4 cases showed annular pancreas. Plain abdomen X-ray examination performed in 113 cases before operation, 76 cases presented double-bubble sign, 12 cases presented single-bubble sign and 5 cases had high-position intestinal obstruction. Upper gastrointestinal radiography (UGI) was performed in 103 cases, which suggested duodenal obstruction in 102 cases. Operations were performed in all cases, of which 69 cases were operated under laparoscopy including 1 case converted to open laparotomy. The mean fasting time after surgery was (7.8±2.7) d, and the mean length of hospital stay was (16.9±10.1) d. Five patients had postoperative complications. The incidence of postoperative complications in antenatal abnormal group was lower than that in the antenatal non-abnormal group (<0.05); the average fasting time in laparoendscopic surgery group was shorter than that in traditional laparotomy group (<0.05).@*CONCLUSIONS@#Neonates with recurrent vomiting early after birth should be highly suspected to have annular pancreas. The fetal chromosome examination should be performed with abnormal antenatal screening. Surgery is the only effective way to diagnose and treat annular pancreas, and laparoscopic surgery could be the first choice for experienced doctors.

Duodenal Stricture due to Necrotizing Pancreatitis following Endoscopic Ultrasound-Guided Ethanol Ablation of a Pancreatic Cyst: A Case Report

The frequency of incidental detection of pancreatic cystic lesions (PCLs) is increasing because of the frequent use of cross-sectional imaging. The appropriate treatment for PCLs is challenging, and endoscopic ultrasound-guided ablation for PCLs has been reported in several studies. Although the feasibility and efficacy of this therapeutic modality have been shown, the safety issues associated with the procedure are still a concern. We present a case of a 61-year-old man who underwent ultrasound-guided ethanol ablation for PCL and needed repeated endoscopic balloon dilatation for severe duodenal stricture caused by necrotizing pancreatitis after the cyst ablation therapy.

Bouveret syndrome, a rare form of gallstone ileus. case report

ABSTRACT Introduction: Bouveret syndrome is a rare form of gallstone ileus that causes gastric obstruction due to the presence of a gallstone in the pylorus or duodenum, secondary to biliodigestive fistula. This condition is difficult to diagnose and one of its main complications is hemorrhage in the digestive tract. Two-stage surgical management is recommended, although it can also be managed through upper endoscopy in gallstones smaller than 2.5cm. Prognosis and postoperative period are good. Clinical case: 63-year-old patient with a clinical picture of 15 days of pain in the epigastrium and bilious vomiting. Imaging showed a calcified mass in the second part of the duodenum, which was surgically treated by entering the jejunum, performing an enterotomy and extracting the gallstone. The patient was discharged on the fifth day without any symptoms. Conclusion: Bouveret syndrome is a rare entity that requires better medical assessment and ancillary imaging techniques to achieve a timely diagnosis.

RESUMEN Introducción. El síndrome de Bouveret es una entidad poco frecuente de íleo biliar que provoca obstrucción gástrica debido a la presencia de un lito biliar a nivel de píloro o duodeno y secundaria a una fistula biliodigestiva. Esta enfermedad es de difícil diagnóstico y una de sus complicaciones es la hemorragia digestiva alta; su manejo es quirúrgico y se recomienda en dos tiempos, aunque se puede manejar por endoscopia alta en aquellos cálculos <2.5cm. El pronóstico es bueno, con un post-operatorio sin novedades. Presentación del caso. Paciente de 63 años con cuadro clínico de 15 días de evolución de dolor en epigástrico y vómitos biliosos incontables. Se realizaron imágenes diagnósticas donde se evidenció masa calcificada en duodeno II, por lo que la paciente fue intervenida quirúrgicamente: se progresó el cálculo a yeyuno, se realizó enterotomía y se extrajo el lito. Al quinto día fue dada de alta sin novedades. Conclusión. El síndrome de Bouveret es una entidad rara que requiere de una adecuada valoración médica y de métodos auxiliares de imágenes para un diagnóstico oportuno.

Anorectal Malformation with Associated Duodenal Obstruction and Uterus Didelphys / Malformación anorrectal asociada con obstrucción duodenal y útero didelfo

ABSTRACT Anorectal malformations have long been associated with multiple other anomalies, commonly referred to as the VACTERL complex. We present a case of a newborn baby girl with an unusually high number of associated anomalies, including the rarely encountered condition of uterus didelphys.

RESUMEN Las malformaciones anorrectales se han asociado por mucho tiempo con otras anomalías, conocidas comúnmente como asociación VACTERL. Presentamos el caso de una niña recién nacida con un número inusualmente alto de anomalías asociadas, incluyendo una condición raramente encontrada conocida como útero didelfo.

Surgical management of the cases with both biliary and duodenal obstruction

Endoscopic management is presently the recommended first-line of treatment for biliary strictures. However, surgery still has an important role especially for biliary obstruction (BO) with duodenal obstruction. Even though endoscopic treatment for concurrent BO and gastric-outlet obstruction has been proposed, it is still not widespread. Duodenal obstruction is often associated with malignant BO which makes endoscopic treatment more challenging. Biliary and gastrointestinal double bypass with Roux-en-Y hepaticojejunostomy and gastrojejunostomy is the most common surgical intervention for malignant biliary and gastric-outlet obstruction. A variety of procedures of biliary bypass and gastrointestinal bypass have been reported. According to several studies, mortality rates range from 0% to 7%, while morbidity rates range from 3% to 50%. Higher morbidity was observed in symptomatic patients caused by the disease. Most common morbidity after double bypass was delayed gastric emptying. Recurrence of BO and gastric-outlet obstruction was less frequently seen after surgical bypass compared to after endoscopic treatment. Minimally invasive approach has been applied to double bypass. Studies showed that laparoscopic double bypass has a shorter hospital stay and reduced postoperative pain; however, due to its technical demand, it is still presently an uncommon procedure. Robotic bypass surgery may resolve this issue in the future. Further analyses of outcomes of both surgical and endoscopic treatments are necessary to establish better and suitable palliation options for concurrent biliary and duodenal obstruction caused by unresectable malignant tumors.

Tratamiento mínimamente invasivo del síndrome de Wilkie / Minimally invasive management of Wilkie´s syndrome

Introducción. La compresión de la tercera porción del duodeno debido a la formación de un ángulo inadecuado de la unión aortomesentérica, se configura como el síndrome de arteria mesentérica superior o síndrome de Wilkie. Se trata de una entidad rara, de modo que es escaso su reporte en la literatura y poco aplicado su manejo quirúrgico mínimamente invasivo. Materiales y métodos. Se hace una revisión no sistemática de la literatura y posteriormente se expone el caso de un paciente con síndrome de Wilkie. Se muestran las imágenes de tomografías y un vídeo del procedimiento quirúrgico al que fue sometido. Discusión. El tratamiento quirúrgico del síndrome de la arteria mesentérica superior es el último recurso que se ofrece en pacientes con esta entidad. La duodenoyeyunostomía es el procedimiento con mejor evidencia en pacientes con compromiso severo del estado nutricional. Se describen los puntos esenciales de esta técnica utilizada en el caso que se reporta. Conclusiones. Cualquier entidad que cause la disminución del paquete graso entre la arteria mesentérica superior y la aorta puede causar síndrome de la arteria mesentérica superior. El diagnóstico es de exclusión y constituye un reto para el equipo médico. El tratamiento inicial es conservador, en tanto que la última opción es el manejo quirúrgico, idealmente por vía laparoscópica. Dentro de las técnicas mínimamente invasivas, la duodenoyeyunostomía es una buena herramienta

Introduction: Compression of the third portion of the duodenum due to an inappropriate angle of the aortamesenteric junction is known as the superior mesenteric artery syndrome or Wilkie's syndrome. A rare entity, reason why the reports in the literature are scarce and the minimally invasive surgical management is scarcely used. Materials and methods: A non-systematic review of the literature was carried out, and the case of a patient with Wilkie's syndrome is reported. The images, tomographies and a video of the surgical procedure are presented.Discussion: The surgical management of the superior mesenteric artery syndrome is the ultimate management to be offered in patients with this entity. Duodenojejunostomy is the procedure with the best evidence to be offered to patients with severe malnutrition. The essential points of this technique, used for the case reported, are described. Conclusions: Any entity that causes the reduction of the fatty pack between the superior mesenteric artery and the aorta can cause superior mesenteric artery syndrome. The diagnosis is made by exclusion and constitutes a challenge for the medical team. The initial treatment is conservative, and the last option is the surgical management, ideally laparoscopic; among the minimally invasive techniques, duodenojejunostomy is a good tool