Melanoma metastásico en intestino delgado: causa infrecuente de perforación: reporte de caso / Metastatic melanoma in the small intestine: infrequent cause of perforation: case report / Melanoma metastático em intestino delgado: causa rara de perfuração: relato de caso

El intestino delgado es el sitio de asiento más frecuente del melanoma metastásico. Su diagnóstico es un desafío por cursar asintomático o con síntomas inespecíficos. Son pocos los casos que presentan complicaciones, siendo infrecuente la peritonitis por perforación. El objetivo del trabajo es comunicar el caso clínico de una peritonitis por perforación de una metástasis de melanoma en intestino delgado. Caso clínico: Paciente de sexo masculino de 66 años con diagnóstico de melanoma de cuello y secundario óseo, encefálico y pulmonar, fue intervenido de urgencia por peritonitis aguda por perforación de metástasis en intestino delgado. El estudio histológico confirmó secundarismo de melanoma cutáneo. Conclusión: Sabiendo que el yeyuno íleon es el sitio de asiento más frecuente de las metástasis de melanoma, ante la presencia de síntomas digestivos inespecíficos o anemia se debe sospechar su compromiso y evaluar posibles alternativas terapéuticas.

The small intestine is the most frequent site of metastatic melanoma. However, its diagnosis continues to be a challenge since it is usually asymptomatic or with non-specific symptoms. Few cases result in complications, peritonitis due to perforation being infrequent. The objective of the work is to report a clinical case of peritonitis due to perforation of a melanoma metastasis in the small intestine. Clinical case: A 66-year-old male patient diagnosed with melanoma of the neck and secondary bone, brain and lung melanoma, underwent emergency surgery for acute peritonitis due to perforation of metastasis in the small intestine, which was resected and anastomosed. The histology confirmed the secondary nature of the cutaneous melanoma. Conclusion: Knowing that the jejunum-ileum is the most frequent site of melanoma metastases, in the presence of non-specific digestive symptoms or anemia, its involvement should be suspected and possible therapeutic alternatives should be evaluated.

O intestino delgado é o local mais frequente de melanoma metastático. O diagnóstico é um desafio por ser assintomático ou apresentar sintomas inespecíficos. Há poucos casos que apresentam complicações, sendo pouco frequente a peritonite por perfuração. O objetivo deste trabalho é relatar um caso clínico de peritonite por perfuração de metástase de melanoma no intestino delgado. Caso clínico: Paciente do sexo masculino, 66 anos, diagnosticado com melanoma no pescoço com metástase óssea, cefálica e pulmonar. Foi submetido a cirurgia de emergência por peritonite aguda por perfuração de metástases do intestino delgado. O estudo histológico confirmou melanoma cutâneo. Conclusão: Sabendo que o jejuno e o íleo é o local mais frequente de metástase de melanoma, na presença de sintomas digestivos inespecíficos ou anemia deve-se suspeitar de seu acometimento e avaliar possíveis alternativas terapêuticas.

Eficacia de la impronta citológica peritoneal para decidir cuándo detener los lavados peritoneales programados / Efficacy of Peritoneal Cytological Imprinting in Deciding When to Stop Scheduled Peritoneal Lavages

Introducción: La no existencia de un parámetro preestablecido que permita determinar el momento preciso para suspender los lavados peritoneales programados, conlleva a que muchas veces se realice un número insuficiente de ellos, o tal vez estos se prolonguen de forma innecesaria y aumentan las probabilidades de fallecimiento del paciente. Objetivo: Determinar la eficacia de la impronta citológica peritoneal para decidir cuándo detener los lavados peritoneales programados. Métodos: Se realizó un estudio descriptivo de exactitud diagnóstica, en una serie de casos, con recogida prospectiva de datos desde enero de 2010 hasta diciembre de 2014, en el Hospital Provincial Clínico-Quirúrgico Docente "Celia Sánchez Manduley. La muestra quedó conformada por 42 pacientes que fueron tratados por peritonitis secundaria persistente. Se clasificaron según cuatro categorías de correlación y se tomó como estándar de referencia a la biopsia por parafina. Resultados: Las muestras con inflamación aguda peritoneal y curación de la inflamación peritoneal se identificaron correctamente en 39/42 casos, por lo tanto, el porcentaje predictivo global de la impronta citológica fue del 92,86 por ciento. La sensibilidad en el diagnóstico de inflamación aguda peritoneal fue del 100 por ciento, la especificidad del 92,68 por ciento, el valor predictivo positivo fue del 24,99 por ciento y el valor predictivo negativo del 100 por ciento. Las razones de verosimilitudes positiva y negativa fueron 13,67 y 0, respectivamente. El coeficiente (κ) fue de 0,376. Conclusiones: La impronta citológica peritoneal constituye un método diagnóstico eficaz para descartar inflamación aguda peritoneal cuando el resultado es negativo y se consideró de gran utilidad para detener los lavados peritoneales programados(AU)

Introduction: The lack of a pre-established parameter that allows determining the precise moment to suspend the scheduled peritoneal lavages, often leads to performing insufficient number of them, or perhaps these are unnecessarily prolonged, increasing the probability of the patient´s death. Objective: To determine the efficacy of peritoneal cytological imprinting in deciding when to stop scheduled peritoneal lavages. Methods: A descriptive study of diagnostic accuracy was carried out, in a series of cases, with prospective data collection in the five-year period from 2010 to 2014 at Celia Sánchez Manduley Provincial Clinical-Surgical Teaching Hospital. The sample was made up of 42 patients who were treated for persistent secondary peritonitis. They were classified according to four correlation categories, taking paraffin biopsy as reference standard. Results: Samples with acute peritoneal inflammation and healing of peritoneal inflammation were correctly identified in 39/42 cases. Therefore, the global predictive percentage of the cytological imprint was 92.86 percent. The sensitivity in the diagnosis of acute peritoneal inflammation was 100 percent, the specificity was 92.68 percent, the positive predictive value was 24.99 percent, and the negative predictive value was 100 percent. The positive and negative likelihood ratios were 13.67 and 0, respectively. Cohen's kappa coefficient (κ) was 0.376. Conclusions: The peritoneal cytological imprint is an effective diagnostic method to rule out acute peritoneal inflammation when the result is negative and it was considered very useful to stop scheduled peritoneal lavages(AU)

Clinical Characteristics and Treatment Outcome of Pseudomonas Peritoneal Dialysis-associated Peritonitis / 中国医学科学院学报

Objective To explore the clinical characteristics and treatment of Pseudomonas peritoneal dialysis-associated peritonitis(PsP). Methods The data of patients receiving peritoneal dialysis in four tertiary hospitals in Jilin province from 2015 to 2019 were retrospectively analyzed.According to the etiological classification,the patients with peritoneal dialysis-associated peritonitis(PDAP)were classified into PsP group and non-PsP group.The incidence of PsP was calculated,and the clinical characteristics and treatment outcomes of the two groups were compared.Kaplan-Meier method was used to draw the survival curve,and Cox regression was performed to analyze the risk factors affecting the technical failure of PsP.The treatment options of Pseudomonas aeruginosa-caused PDAP and the drug sensitivity of PsP were summarized. Results A total of 1530 peritoneal dialysis patients with complete data were included in this study,among which 439 patients had 664 times of PDAP.The incidence of PsP was 0.007 episodes/patient-year.PsP group had higher proportion of refractory peritonitis(41.38% vs.19.69%,P=0.005),lower cure rate(55.17% vs.80.79%, P=0.001),and higher extubation rate(24.14% vs.7.09%,P=0.003)than non-PsP group.The technical survival rate of PsP group was lower than that of non-PsP group(P<0.001).Multivariate Cox regression analysis showed that Pseudomonas aeruginosa was an independent risk factor for technical failure in patients with PsP(HR=9.020,95%CI=1.141-71.279,P=0.037).Pseudomonas was highly sensitive to amikacin,meropenem,and piperacillin-tazobactam while highly resistant to compound sulfamethoxazole,cefazolin,and ampicillin. Conclusion The treatment outcome of PsP is worse than that of non-PsP,and Pseudomonas aeruginosa is an independent risk factor for technical failure of PsP.

Ascariasis complicada en un infante / Complicated ascariasis in an infant

Introducción: La ascariasis es una enteroparasitosis con alta prevalencia en la población pediátrica tercermundista, la cual puede asociarse a otras enfermedades intestinales y tener graves complicaciones que requieren tratamiento quirúrgico. Objetivo: Informar el caso de un infante operado por coinfección de ascariasis intestinal y fiebre tifoidea complicadas. Presentación del caso: Paciente masculino de 9 años de edad asistido y operado en el hospital provincial N´gola Kimbanda de la provincia Namibe, Angola, por presentar evidencia clínica de peritonitis aguda generalizada por perforación intestinal de causa tifoidea y por cuyo orificio salían además áscaris lumbricoides vivos. Su evolución no fue satisfactoria y falleció 24 horas después de la operación. Conclusiones: El diagnóstico y tratamiento quirúrgico oportuno de la coinfección letal de ascariasis y fiebre tifoidea complicadas permitirá disminuir la morbilidad y mortalidad por esta prevalente asociación(AU)

Introduction: Ascariasis is an enteroparasitosis with high prevalence in the third-world pediatric population, which can be associated with other bowel diseases and have serious complications that require surgical treatment. Objective: Report the case of an infant operated by the co-infection of complicated intestinal ascariasis and typhoid fever. Case presentation: 9-year-old male patient attended and operated at N'gola Kimbanda Provincial Hospital in Namibe Province, Angola, after presenting clinical evidence of generalized acute peritonitis due to intestinal perforation of typhoid-causing and through which live ascaris lumbricoide also came out. His evolution was unsatisfactory and he died 24 hours after the operation. Conclusions: The timely diagnosis and surgical treatment of lethal co-infection of complicated ascariasis and typhoid fever will reduce morbidity and mortality from this prevalent association(AU)

Morbimortalidad de las reintervenciones en la cirugía abdominal urgente y electiva / Morbidity and Mortality for Re-interventions in Urgent and Elective Abdominal Surgery

Introducción: Las reintervenciones en la cirugía abdominal, son causa de una alta mortalidad en los servicios de cirugía general. Objetivo: Caracterizar morbimortalidad de las reintervenciones de la cirugía abdominal urgente y electiva en el servicio de cirugía general del Hospital Universitario "Manuel Ascunce Domenech". Métodos: Se realizó un estudio observacional descriptivo transversal, de los pacientes que requirieron de reintervención quirúrgica abdominal. El universo estuvo conformado por 236 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: Predominó el grupo de edades de 40-49 años, así como el sexo masculino, con un 25 por ciento y 64,8 por ciento, respectivamente. En cuanto al tiempo en que se realizó la reintervención 72,5 por ciento se realizó luego de las 48 horas. El 88,6 por ciento de los pacientes resolvió la causa que lo originó en la primera reintervención. Las causas más frecuentes fueron la peritonitis generalizada seguida de los abscesos intrabdominales con un 19,5 por ciento y 17,4 por ciento respectivamente. La mortalidad fue de 30,1 por ciento y el tromboembolismo pulmonar la causa directa de muerte en 12,3 por ciento de los casos. Conclusiones: Casi la totalidad de los casos fueron reintervenidos luego de las 48 horas y las dos terceras partes resolvieron en la primera intervención. La peritonitis generalizada y los abscesos intrabdominales fueron la causa de la reintervención en un número importante(AU)

Introduction: Abdominal surgery re-interventions cause high mortality in general surgery services. Objective: To characterize morbidity and mortality of urgent and elective abdominal surgery re-interventions in the general surgery service of Manuel Ascunce Domenech University Hospital. Methods: A cross-sectional, descriptive, observational study was carried out with patients who required abdominal surgical re-intervention. The universe consisted of 236 patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: There was a predominance of the age group 40-49 years and the male sex, accounting for 25 percent and 64.8 percent, respectively. Regarding time of performance of re-intervention, 72.5 percent was carried out after 48 hours. 88.6 percent of the patients had, in the first re-intervention, a solution for the cause that originated it. The most frequent causes were generalized peritonitis, followed by intraabdominal abscesses, accounting for 19.5 percent and 17.4 percent, respectively. Mortality was 30.1 percent and pulmonary embolism was the direct cause of death in 12.3 percent of cases. Conclusions: Almost all the cases were re-intervened after 48 hours and two thirds had a solution the first re-intervention. Generalized peritonitis and intraabdominal abscesses were the cause of re-intervention, in a significant number(AU)

Hartmann procedure or resection with primary anastomosis for treatment of perforated diverticulitis? systematic review and meta-analysis / Procedimento de hartmann ou ressecção com anastomose primária para tratamento da diverticulite perfurada? revisão sistematizada e metanálise

ABSTRACT Background: The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity. Aim: To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment. Method: Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion. Results: There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion. Conclusion: Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.

RESUMO Racional: O procedimento a Hartmann permanece sendo o tratamento de escolha da maioria dos cirurgiões para o tratamento cirúrgico de urgência da diverticulite perfurada, entretanto está associado com altas taxas de não reversão da ostomia e de morbidade pós-operatória. Objetivo: Estudar os resultados após o procedimento de Hartmann vs. ressecção com anastomose primária, com ou sem ileostomia, para o tratamento da diverticulite perfurada com peritonite purulenta ou fecal (grau de Hinchey III ou IV), e comparar as vantagens entre as duas formas de tratamento. Método: Busca sistemática na literatura de artigos observacionais e randomizados comparando ressecção com anastomose primária vs. procedimento de Hartmann no tratamento de urgência da diverticulite perfurada. Analisar como desfechos primários a mortalidade após a operação de urgência e a morbidade geral após ela; como desfechos secundários, a morbidade severa após a operação de urgência, as taxas de não reversão da ostomia, a morbidade geral e severa após a reversão. Resultados: Não houve diferenças significativas entre os procedimentos cirúrgicos para mortalidade, morbidade geral e morbidade severa. Contudo, as diferenças foram significativas estatisticamente favorecendo anastomose primária na comparação com procedimento de Hartmann nos desfechos taxas de não reversão do estoma, morbidade geral e morbidade severa após reversão. Conclusão: A anastomose primária apresenta-se como boa alternativa ao procedimento de Hartmann, sem aumento de mortalidade e morbidade, e com melhores resultados na operação de reconstrução do trânsito intestinal.

Clinical characteristics and treatment outcomes of first peritonitis in patients receiving long-term peritoneal dialysis: a multicenter study / 南方医科大学学报

OBJECTIVE@#To analyze the clinical characteristics and treatment outcomes of the first episode of peritoneal dialysis-associated peritonitis (PDAP) in patients receiving long-term peritoneal dialysis.@*METHODS@#The clinical data of patients with the first episode of PDAP in 4 general hospitals in Jilin Province from 2013 to 2019 were collected retrospectively. According to the duration of dialysis, the patients were divided into long-term (≥36 months) and short-term (< 36 months) dialysis groups for comparison of the clinical data, treatment outcomes and long-term prognostic events.@*RESULTS@#A total of 625 patients with PDAP were enrolled, including 93 on long-term and 532 on short-term dialysis. Compared with those on short-term dialysis, the patients on long-term dialysis had significantly higher hemoglobin levels and lower glomerular filtration rates when the first episode of PDAP occurred (@*CONCLUSIONS@#Compared with those on short-term dialysis, patients on long-term dialysis are prone to gram-negative bacterial infection when the first episode of PDAP occurs with worse treatment outcomes but similar long-term outcomes. Long-term dialysis is an independent risk factor of extubation and treatment failure for the first episode of PDAP, and fungal and mixed bacterial infections are independent risk factors for treatment failure of the first PDAP in patients with long-term dialysis.

Laparotomía abreviada y terapia de presión negativa para el cierre temporal del abdomen como tratamiento de la peritonitis diverticular Hinchey III/IV / Abbreviated laparotomy and negative pressure therapy for temporary closure of the abdomen as treatment of diverticular peritonitis Hinchey III/IV

Introducción: Los pacientes que se presentan con cuadros de peritonitis de origen diverticular (estadios Hinchey III o IV) en un contexto de sepsis severa con inestabilidad hemodinámica (shock séptico) la realización de anastomosis primaria presenta una alta tasa de dehiscencia anastomótica y mortalidad operatoria, aconsejándose la realización de una resección y abocamiento a la manera de Hartmann. Sin embargo, la alta tasa de complicaciones relacionadas a la confección del ostoma, la complejidad de la cirugía de restauración del tránsito intestinal, asociado a que entre el 40 % y el 60 % de los Hartmann no se reconstruyen, ha estimulado a que se intenten otras variables de resolución para esta compleja y grave patología. Diversas publicaciones en los últimos años han propuesto la táctica de "cirugía del control del daño" con el objeto de disminuir la morbimortalidad de estos gravísimos cuadros sépticos y a su vez reducir la tasa de ostomías. El objetivo de este trabajo es presentar nuestra experiencia inicial con esta modalidad de manejo de la peritonitis diverticular Hinchey III/IV sepsis severa e inestabilidad hemodinámica (shock séptico) y realizar una revisión bibliográfica del tema. Material y método: Estudio observacional, descriptivo, de series de casos. Entre noviembre de 2015 y diciembre de 2016. Servicio de coloproctología del complejo médico hospitalario Churruca-Visca de la ciudad de Buenos Aires y práctica privada de los autores. Se utilizó la técnica de laparotomía abreviada y cierre temporal del abdomen mediante un sistema de presión negativa. Resultados: En el periodo descripto se operaron 17 pacientes con peritonitis generalizada purulenta o fecal de origen diverticular. Catorce casos fueron Hinchey III (82,36%) y 3 casos Hinchey IV (17,64%). En 3 casos se observó inestabilidad hemodinámica en el preoperatorio o intraoperatorio. Todos ellos correspondientes al estadio IV de Hinchey. Se describen los 3 casos tratados mediante esta táctica quirúrgica. Discusión: La alta tasa de morbimortalidad de este subgrupo de pacientes incentivó a diversos grupos quirúrgicos a implementar la técnica de control del daño, permitiendo de esta manera estabilizar a los pacientes hemodinámicamente y en un segundo tiempo evaluar la reconstrucción del tránsito intestinal. En concordancia con estas publicaciones, dos de nuestros pacientes operados con esta estrategia, pudieron ser anastomosados luego del segundo lavado abdominal. Conclusión: En pacientes con peritonitis diverticular severa asociado a shock séptico el concepto de laparotomía abreviada con control inicial del foco séptico, cierre temporal del abdomen con sistema de presión negativa y posterior evaluación de la reconstrucción del tránsito intestinal, es muy alentador. Permitiendo una disminución de la morbimortalidad como así también del número de ostomías. (AU)

Introduction: Patients presenting with diverticular peritonitis (Hinchey III or IV stages) in a context of severe sepsis with hemodynamic instability (septic shock), performing primary anastomosis has a high rate of dehiscence anastomotic and operative mortality, advising the realization of a resection and ostoma in the manner of Hartmann. However, the high rate of complications related to performing of ostoma, the complexity of intestinal transit restoration surgery, associated with the 40% to 60% of Hartmann reversal not performed, has encouraged other variables to be attempted resolution for this complex and serious pathology. Several publications in recent years have proposed the tactic of "damage control surgery" in order to reduce the morbidity of these serious septic charts while reducing the rate of ostomies. The objective of this study is to present our initial experience with this modality of management of the diverticular peritonitis Hinchey III/IV severe sepsis and hemodynamic instability (septic shock) and to carry out a bibliographic review of the subject. Material and method: Observational, descriptive study of case series. Between November 2015 and December 2016. Coloproctology service of the Churruca-Visca hospital medical complex in the city of Buenos Aires and private practice of the authors. The technique of abbreviated laparotomy and temporary closure of the abdomen was used by a negative pressure system. Results: In the period described, 17 patients with generalized purulent or fecal peritonitis of diverticular origin were operated. Fourteen cases were Hinchey III (82.36%) and 3 cases Hinchey IV (17.64%).In 3 cases, hemodynamic instability was observed in the preoperative or intraoperative period. all of them corresponding to Hinchey's Stage IV. The 3 cases treated using this surgical tactic are described. Discussion: The high morbidity rate of this subgroup of patients encouraged various surgical groups to implement the damage control technique, thus allowing patients to stabilize hemodynamically and in a second time evaluate reconstruction intestinal transit. In line with these publications, two of our patients operated on with this strategy could be anastomosated after the second abdominal wash. Conclusion: In patients with severe diverticular peritonitis associated with septic shock, the concept of abbreviated laparotomy with initial control of the septic focus, temporary closure of the abdomen with negative pressure system and subsequent evaluation of transit reconstruction intestinal, it's encouraging. Allowing a decrease in morbidity as well as the number of ostomies. (AU)

Diagnóstico prenatal y enfrentamiento postnatal de peritonitis meconial, a propósito de un caso / Prenatal diagnosis and postnatal confrontation of meconial peritonitis: a clinical case

INTRODUCCIÓN La peritonitis meconial (PM) es una peritonitis localizada o generalizada, aséptica, química o de cuerpo extraño; producto del paso de meconio a la cavidad peritoneal y esta correlacionada con la perforación prenatal del tracto digestivo. Se presenta en 1 de cada 30.000 recién nacidos (RN). El diagnostico ecográfico prenatal mejora los resultados perinatales, el hallazgo más frecuente es la ascitis. La PM requiere un tratamiento multidisciplinario urgente, la mayoría es de resolución quirúrgica. OBJETIVO Dar a conocer una patología infrecuente, que requiere un alto grado de sospecha diagnostica para otorgar un manejo perinatal específico y oportuno. Caso clínico Primigesta de 29 años sin antecedentes mórbidos, cursando embarazo controlado de 36+5 semanas. En control ecográfico se evidencia ascitis fetal. Se hospitaliza en alto riesgo obstétrico, descartando patología metabólica e infecciosa. A las 37 semanas por cesárea de urgencia, se obtiene RN con distensión abdominal y hepatomegalia. En laparotomía exploradora se evidencia asas intestinales indemnes. En re intervención se encuentra hernia de íleon distal perforada, se confecciona ostomia, evoluciona favorablemente y es dado de alta. DISCUSIÓN Es fundamental considerar la PM dentro de los diagnósticos diferenciales de ascitis fetal. Un diagnóstico oportuno mejora los resultados perinatales y permite prevenir posibles complicaciones.

INTRODUCTION Meconial peritonitis (PM) is localized or generalized peritonitis, aseptic, chemical or strange body; a product of meconium steps to the peritoneal cavity and is correlated with prenatal perforation of the digestive tract. It occurs in 1 in 30,000 newborns. Prenatal ultrasound diagnosis improves perinatal outcomes, the most frequent finding is ascites. PM requires urgent multidisciplinary treatment, most of cases need surgical resolution. OBJECTIVE To present an infrequent pathology, which requires a high degree of diagnostic suspicion to grant a specific and timely perinatal management. Clinical case Pregnant 29 years old woman without morbid history, 36 weeks of controlled pregnancy. Ultrasound control shown fetal ascites. He is hospitalized at high obstetric risk, ruling out metabolic and infectious pathology. At 37 weeks by emergency caesarean section, is obtained a baby boy with abdominal distension and hepatomegaly. In exploratory laparotomy there are undamaged intestinal handles. In re intervention it is noted herniated perforated distal ileum, ostomy is made. Patient evolves favourably and is discharged. DISCUSSION It is essential consider PM within the differential diagnoses of fetal ascites. An opportune diagnosis improves the perinatal results and could avoids possible complications.

Peritonitis manejada por laparoscopia como método terapéutico eficaz / Peritonitis treated by laparoscopy as an effective treatment

La peritonitis es una de las principales complicaciones de las urgencias abdominales. La laparoscopia sirve tanto para el manejo diagnóstico y terapéutico del abdomen agudo; en manos expertas la morbimortalidad de este método es mínima. Objetivo: El objetivo es comprobar la eficacia de la laparoscopia en pacientes con peritonitis secundaria realizando una sola cirugía sin necesidad de reintervenciones, asegurando el menor daño de la pared abdominal, evitando la laparotomía. Materiales y métodos: Estudio retrospectivo, se incluyeron pacientes con diagnostico final de peritonitis y manejados con técnica laparoscópica, abarcando un periodo de mayo del 2011 a julio del 2016, ingresados a la Clínica Nuestra Señora de Fátima, Pasto, Colombia. Resultados: La muestra fueron 67 pacientes. Los resultados indican una edad promedio de 45 años, edad máxima 94 y mínima 17 años, ± de 20,6; predomina el sexo Femenino en un 55,2% (n=37); siendo el 73,1% (n=49) del área urbana. El tiempo de evolución promedio de la patología fue de 4 días. No hubo casos de mortalidad en la población objeto de estudio. Conclusión: La técnica laparoscópica, el lavado exhaustivo de la cavidad abdominal, la inserción del dren mixto y el tratamiento adecuado de antibiótico, se constituye en una técnica segura en el paciente ya que evito reintervenciones quirúrgicas, riesgo de infecciones, ausencia de íleo paralitico y sangrado, evitando así la laparostomía y el defecto gigante de la pared abdominal.

Peritonitis is one of the main complications of abdominal emergencies. Laparoscopy serves both for the diagnostic and therapeutic management of the acute abdomen; in expert hands the morbimortality of this method is minimal. Objective: The objective is to verify the efficacy of laparoscopy in patients with secondary peritonitis performing a single surgery without the need for reinterventions, ensuring the least damage of the abdominal wall, avoiding laparotomy. Material and methods: Retrospective study included patients with final diagnosis of peritonitis and managed with laparoscopic technique, covering a period from May 2011 to July 2016, admitted to Clínica Nuestra Señora de Fátima, Pasto, Colombia. Results: The sample was 67 patients. The results indicate an average age of 45 years, maximum age 94 and minimum 17 years, ± 20.6; female sex predominates in 55.2% (n = 37); being 73.1% (n = 49) of the urban area. The mean evolution time of the disease was 4 days. There were no cases of mortality in the study population. Conclusion: The laparoscopic technique, thorough cleaning of the abdominal cavity, insertion of the mixed drainage and adequate antibiotic treatment, constitutes a safe technique in the patient since it prevents surgical reinterventions, risk of infections, absence of paralytic ileus and bleeding, thus avoiding laparostomy and the giant defect of the abdominal wall.

Ascites and Encapsulating Peritonitis in Endometriosis: a Systematic Review with a Case Report / Endometriose com ascite e peritonite encapsulante: uma revisão sistemática com descrição de um caso clínico

Abstract Endometriosis can have several different presentations, including overt ascites and peritonitis; increased awareness can improve diagnostic accuracy and patient outcomes. We aimto provide a systematic review and report a case of endometriosis with this unusual clinical presentation. The PubMed/MEDLINE database was systematically reviewed until October 2016. Women with histologically-proven endometriosis presenting with clinically significant ascites and/or frozen abdomen and/or encapsulating peritonitis were included; thosewith potentially confounding conditionswere excluded.Our search yielded 37 articles describing 42 women, all of reproductive age. Ascites was mostly hemorrhagic, recurrent and not predicted by cancer antigen 125 (CA-125) levels. In turn, dysmenorrhea, dyspareunia and infertility were not consistently reported. The treatment choices and outcomes were different across the studies, and are described in detail. Endometriosis should be a differential diagnosis of massive hemorrhagic ascites in women of reproductive age.

Resumo A endometriose pode ter várias apresentações, incluindo ascite e peritonite, que são apresentações incomuns. O aumento da conscientização sobre essa doença podemelhorar a precisão diagnóstica e os resultados das pacientes. Nosso objetivo é fornecer uma revisão sistemática e relatar um caso de endometriose com esta apresentação clínica incomum. O banco de dados PubMed/MEDLINE foi revisado sistematicamente até outubro de 2016. Foram incluídas mulheres comendometriosedemonstrada histologicamente, compresença de ascite clinicamente significativa e/ou abdômen congelado e/ou peritonite encapsulante; foram excluídas aquelas com comorbidades que pudessem provocar confusão. A pesquisa selecionou 37 artigos que descrevem42mulheres, todas emidade reprodutiva. A ascite foi principalmente hemorrágica, recorrente, e não indicada pelos níveis de antígeno associado ao câncer 125 (AC-125). Por sua vez, a dismenorreia, a dispareunia e a infertilidade não foram relatadas de forma consistente. As escolhas e os resultados do tratamento foram diferentes entre os estudos, e são descritos em detalhes. A endometriose deveria ser um diagnóstico diferencial de ascite hemorrágica maciça em mulheres em idade reprodutiva.

Peritoneal dialysis-related eosinophilic peritonitis: a case report and literature review / 北京大学学报(医学版)

Peritoneal dialysis (PD)-related peritonitis is recognized as a common complication of peritoneal dialysis. Eosinophilic peritonitis is a rare type of non-infection PD-related peritonitis. Eosinophilic peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients was first reported in 1967. The cause of eosinophilic peritonitis is obscure, however it may be related to some etiologies: (1) hypersensitivity to PD materials, including catheter or dialysate; (2) bacteria, fungal or mycobacterium tuberculosis infection. Clinical investigations include asymptomatic cloudy PD effluent, fever, abdominal pain and eosinophil count elevate in PD effluent. Eosinophilic peritonitis is usually mild and self-limited. With the development of PD, more eosinophilic peritonitis cases and researches were reported. Here, we report a patient on CAPD with eosinophilic peritonitis. A 71-year-old female patient developed end-stage renal disease for 4 years and underwent CAPD (2 000 mL of 1.5% dialysis solution with four exchanges daily) for 5 months. With a history of unclean food, she was hospitalized for complaints of diarrhea, fever and cloudy peritoneal effluent for 10 days. Dialysis effluent showed an elevated white blood cell (WBC) count of 1 980 cell/mm3, with 60% polymorphonuclear cells. She was diagnosed as PD-related peritonitis, and therapy was initiated with intraperitoneal ceftazidime 1 g once a day and vancomycin 500 mg every other day. She was admitted to the hospital as the symptoms were not relieved. Her peripheral blood cell count showed a total WBC count of 6 940 cells/mm3, 36.8% eosinophil. Her PD effluent analysis showed turbidity, total WBC count of 1 480 cells/mm3, and 83% polymorphonuclear cells. Her dialysate bacteria culture, fungus culture, polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR), acid-fast stain were all negative. On admission day 4, the treatments were changed to levofloxacin 200 mg once a day and vancomycin 500 mg every other day. After two weeks of antibiotics treatment, patient's symptoms were not completely improved and her dialysis effluent remained cloudy. Her blood eosinophil count elevated to 36.8%，eosinophil proportion in PD effluent>90% and PD effluent pathological findings showed eosinophil>90%. Eosinophilic peritonitis was diagnosed and a decision was made to give loratadine daily dose of 10 mg orally. The possible reasons might be the patient's allergy to some components of PD solution or connection systems in the beginning of PD, and this bacterial peritonitis episode, as well as the application of vancomycin, might lead to the fact that eosinophilic peritonitis acutely developed. For there was no improvement in clinical symptoms, loratadine was stopped, and the patient was discharged 18 days later, and received follow-up closely. Two months later, eosinophil count in blood and PD fluid decreased to normal range with no symptom. This case reminds us that in any PD-related peritonitis patient with prolonged symptoms after appropriate antibiotic therapy, and typical clinical symptoms, the diagnosis of eosinophilic peritonitis should be considered. For the count and percentage of eosinophils are not routinely reported in most laboratories, doctors need to contact the department of laboratory and the department of pathology, to confirm the cell count and proportion of eosinophils in dialysis effluent, so as to make the definite diagnosis, which can not only avoid antibiotics overuse, but also avoid antibiotics-induced eosinophilic peritonitis (such as vancomycin).

Mortalidad por peritonitis secundaria en el Hospital General Docente Dr Agostinho Neto de Guantánamo. Factores determinantes / Mortality due to secondary peritonitis in the General Teaching Hospital Dr Agostinho Neto from Guantánamo. Determining factors

Introducción: en la unidad de cuidados intensivos no siempre se conocen los factores que determinan el pronóstico del paciente con peritonitis. Objetivo: precisar los factores determinantes de la mortalidad por peritonitis secundaria en esta unidad en el Hospital "Dr. Agostinho Neto" durante los años 2014­2016. Método: se realizó un estudio analítico prospectivo y longitudinal de todos los pacientes ingresados en la citada UCI por peritonitis secundaria en los años 2014­2016 (n=70), los que se agruparon según fueran egresados vivos o fallecidos. Se precisaron las variables más relacionadas con la probabilidad de que el paciente falleciera y las más frecuentes en los fallecidos. Se calculó el riesgo absoluto (RA) de cada variable. Resultados: los factores más frecuentes fueron: fiebre (n=53), Síndrome respuesta inflamatoria sistémica (n=51) y la leucocitosis/desviación izquierda (n=51). Los factores con mayor probabilidad de determinar la muerte fueron: fallo multiorgánico (RA 17.8), fluido peritoneal fecaloideo (RA 7.8) y choque séptico (RA 7.3). Conclusión: Los factores que determinan la mortalidad por peritonitis secundaria son: la peritonitis difusa, presencia de fallo multiorgánico, hipoxemia ≤ 85 mmHg y/o Sp02 ≤ 90 %, edad ≥ 60 años, presión intrabdominal poscirugía ≥ 21 cm H2O (15 mmHg), síntomas ≥ 24 h antes de cirugía, choque séptico, fluido peritoneal fecaloideo, origen colónico de la peritonitis(AU)

Introduction: the factors that determine the prognosis of the patient with peritonitis are not always known in the intensive care unit. Objective: to determine the determinants of mortality due to secondary peritonitis in this unit at the Hospital "Dr. Agostinho Neto" during the years 2014-2016. Method: a prospective, longitudinal, and analytical study was conducted of all the patients admitted to the ICU for secondary peritonitis in the years 2014-2016 (n=70), which were grouped according to graduates alive or deceased. The variables most related to the probability of the patient's death and the most frequent in the deceased were specified. The absolute risk (AR) of each variable was calculated. Results: the most frequent factors were: fever (n = 53), systemic inflammatory response syndrome (n = 51) and left leukocytosis/deviation (n = 51); the factors most likely to determine death were multiorgan failure (RA 17.8), fecaloid peritoneal fluid (RA7.8) and septic shock (RA 7.3). Conclusions: The factors that determine mortality due to secondary peritonitis: diffuse peritonitis, presence of multi-organ failure, hypoxemia ≤ 85 mmHg or Sp02 ≤ 90 %, age ≥ 60 years, intra-abdominal pressure after surgery ≥ 21 cm H2O (15 mmHg), symptoms ≥ 24 h before surgery, septic shock, fecaloid peritoneal fluid, colonic origin of peritonitis(AU)

Lesiones iatrogénicas de las vías biliares / Iatrogenic lesions of the biliary tract

Las lesiones iatrogénicas de las vías biliares (LIVB) representan una complicación quirúrgica grave de la colecistectomía laparoscópica (CL). Ocurre frecuentemente cuando se confunde el conducto biliar con el conducto cístico; y han sido clasificados por Strasberg y Bismuth, según el grado y nivel de la lesión. Alrededor del tercio de las LIVB se reconocen durante la CL, al detectar fuga biliar. No es recomendable su reparación inmediata, especialmente cuando la lesión está próxima a la confluencia o existe inflamación asociada. El drenaje debe establecerse para controlar la fuga de bilis y prevenir la peritonitis biliar, antes de transferir al paciente a un establecimiento especializado en cirugía hepatobiliar compleja. En pacientes que no son reconocidos intraoperatoriamente, las LIVB manifiestan tardíamente fiebre postoperatoria, dolor abdominal, peritonitis o ictericia obstructiva. Si existe fuga biliar, debe hacerse una colangiografía percutánea para definir la anatomía biliar y controlar la fuga mediante stent biliar percutáneo. La reparación se realiza seis a ocho semanas después de estabilizar al paciente. Si hay obstrucción biliar, la colangiografía y drenaje biliar están indicados para controlar la sepsis antes de la reparación. El objetivo es restablecer el flujo de bilis al tracto gastrointestinal para impedir la formación de litos, estenosis, colangitis y cirrosis biliar. La hepáticoyeyunostomía con anastomosis en Y de Roux termino-lateral sin stents biliares a largo plazo, es la mejor opción para la reparación de la mayoría de las lesiones del conducto biliar común.

Iatrogenic bile duct injuries (IBDI) represent a serious surgical complication of laparoscopic cholecystectomy (LC). Often it occurs when the bile duct merges with the cystic duct; and they have been ranked by Strasberg and Bismuth, depending on the degree and level of injury. About third of IBDI recognized during LC, to detect bile leakage. No immediate repair is recommended, especially when the lesion is near the confluence or inflammation is associated. The drain should be established to control leakage of bile and prevent biliary peritonitis, before transferring the patient to a specialist in complex hepatobiliary surgery facility. In patients who are not recognized intraoperatively, the IBDI manifest late postoperative fever, abdominal pain, peritonitis or obstructive jaundice. If there is bile leak, percutaneous cholangiography should be done to define the biliary anatomy, and control leakage through percutaneous biliary stent. The repair is performed six to eight weeks after patient stabilization. If there is biliary obstruction, cholangiography and biliary drainage are indicated to control sepsis before repair. The ultimate aim is to restore the flow of bile into the gastrointestinal tract to prevent the formation of calculi, stenosis, cholangitis and biliary cirrhosis. Hepatojejunostomy with Roux-Y anastomosis termino-lateral without biliary stents long term, is the best choice for the repair of most common bile duct injury.

Diagnóstico y seguimiento de 12 casos de peritonitis esclerosante asociada a diálisis peritoneal crónica en Chile: Experience in 12 patients on peritoneal dialysis / Encapsulating peritoneal sclerosis

Background: Encapsulating peritoneal sclerosis (EPS) is a complication of peritoneal dialysis (PD) with a low prevalence but high mortality. It is characterized by peritoneal inflammation and fibrosis with subsequent development of intestinal encapsulation. It is associated with a long lapse on PD, frequent episodes of peritonitis, high glucose solution use, and high peritoneal transport status. Aim: To report the clinical features of patients on PD, who developed EPS. Material and Methods: Review of medical records of 12 patients aged 43 ± 10 years (eight women) who developed EPS. Results: The mean time spent on PD was 98 months. The main clinical manifestations were abdominal pain in 82% and ultrafiltration failure in 63%. In 92%, there was a history of peritonitis and 75% had high peritoneal transport at the time of diagnosis. The main findings in computed tomography were peritoneal calcification and thickening. There was a biopsy compatible with the diagnosis in 10 cases. Treatment consisted in withdrawal from PD, removal of PD catheter and the use of corticoids and tamoxifen. After withdrawal from PD 50% of patients became asymptomatic. The rest had intermittent abdominal pain and altered bowel movements. Two patients died (17%). Conclusions: EPS is a serious complication of PD, which should be suspected in any patient with compatible clinical symptoms, long time on PD, multiple episodes of peritonitis and high peritoneal transport profile.