Megacolon andino y vólvulo del sigmoides de la altura: Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge - Puno, Perú / Andean megacolon and sigmoid volvulus in the high altitude: Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru

Objetivo: El presente estudio describe el manejo médico y quirúrgico del vólvulo de sigmoides debido a dolicomegacolon andino en un hospital a una altitud mayor a 3000 msnm. Material y métodos: Estudio descriptivo, observacional, transversal de 418 pacientes con diagnóstico de vólvulo de sigmoides; admitidos inicialmente por cuadros de obstrucción intestinal, en el Hospital de Juliaca Carlos Monge - Puno, Perú, durante el periodo 2008-2012. Los datos fueron procesados a través del programa SPSS versión 21. Resultados: Se registraron 418 pacientes, la media de edad fue de 60 años, rango 18-89 años, con una proporción hombre/mujer de 3,5/1. El manejo no quirúrgico se hizo en 64 (15,4%), el tratamiento empleado fue de enema salino 20 casos 31% y sonda rectal 44 (69%), se presentó recurrencia en 27 pacientes (45%), los cuales tuvieron cirugía con resección anastomosis primaria, de estos la mortalidad correspondió a 8 pacientes (30%). De los 354 pacientes sometidos a manejo quirúrgico de emergencia 325 fueron sometidos a sigmoidectomia con anastomosis primaria (92%), mientras 29 tuvieron colostomía a lo Hartmann (8%), la morbilidad para ambos procedimientos fue de 52 casos (14,7%), la mortalidad para ambos procedimientos fue de 45 casos (12,7%). Conclusiones: El vólvulo sigmoides debido a megacolon andino tuvo una edad media de 60 años. El 15,4% tuvo manejo no quirúrgico, la tasa de recurrencia fue de 45%, mortalidad de 30%. El 84,7% tuvo manejo quirúrgico; el 92% tuvo resección anastomosis primaria y 8% colostomía a lo Hartmann, la morbilidad fue de 14,7% y la mortalidad de 12,7%.

Objective: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. Material and methods: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. Results: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). Conclusions: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.

Obstrucción colónica por cálculo / Colonic obstruction by gallstone

El íleo biliar es una rara complicación de la colelitiasis, que se caracteriza por presentar clínicamente una obstrucción intestinal mecánica intraluminal, secundaria a la impactación de un cálculo biliar en el tubo digestivo, debido a la existencia de una fístula bilio-entérica. El diagnóstico preoperatorio es difícil, ya que presenta síntomas y signos de obstrucción intestinal, los cuales son muy inespecíficos para sospechar un íleo biliar. El tratamiento de elección en el manejo del íleo biliar es el quirúrgico. Habitualmente se realiza una cirugía en dos tiempos, enterolitotomía como único gesto, sin embargo no hay una técnica quirúrgica definitiva estandarizada. Presentamos el caso de una paciente de 70 años que acude al Departamento de Urgencias con el diagnóstico clínico de obstrucción intestinal mecánica baja, de cuatro días de evolución, como consecuencia de un cálculo impactado en colon sigmoides.

Gallstone ileus is a rare complication of cholelithiasis, which is characterized by clinically presenting as an intraluminal mechanical intestinal obstruction secondary to the impaction of a gallstone in the digestive tract, due to the existence of a biliary-enteric fistula. The preoperative diagnosis is difficult, since it presents symptoms and signs of intestinal obstruction, which are very unspecific to suspect a Biliary Ileus. The treatment of choice in the management of gallstone ileus is surgery; usually is performed in two stages, whole lithotomy as the only gesture, however there is no standardized definitive surgical technique. We present the case of a 70-year-old patient, who attended the emergency department with the clinical diagnosis of low mechanical bowel obstruction, four days of evolution, as a result of a stone impacted in the sigmoid colon.

Vesicoenteric Fistula due to Bladder Squamous Cell Carcinoma

Vesicoenteric fistula is a rare complication of bladder squamous cell carcinoma. We report the case of a 70-year-old male who complained of painless, total gross hematuria. Abdominopelvic computed tomography (CT) revealed an approximately 2.7-cm lobulated and contoured enhancing mass in the bladder dome. We performed partial cystectomy of the bladder dome after transurethral resection of the bladder. The biopsy result was bladder squamous cell carcinoma, with infiltrating serosa histopathologically, but the resection margin was free. Postoperatively, follow-up CT was done after 3 months. Follow-up CT revealed an approximately 4.7-cmx4.0-cm lobulated, contoured, and heterogeneous mass in the bladder dome. A vesicoenteric fistula was visible by cystography. Here we report this case of a vesicoenteric fistula due to bladder squamous cell carcinoma.

Occurrence of dolichocolon without megacolon in chronic Chagas disease patients / Ocorrência de dolicocólon sem megacólon em chagásicos crônicos

INTRODUCTION: Since 1970, lengthening of the rectosigmoid has been suspected to be a solitary manifestation of Chagas colopathy. METHODS: To test this hypothesis, opaque enema was administered on 210 seropositive and 63 seronegative patients, and radiographs in the anteroposterior and posteroanterior positions were examined blind to the serological and clinical findings. The distal colon was measured using a flexible ruler along the central axis of the image from the anus to the iliac crest. RESULTS: Dolichocolon was diagnosed in 31 (14.8%) seropositive and 3 (4.8%) seronegative patients. The mean length was 57.2 (±12.2)cm in seropositive patients and 52.1 (±8.8)cm in the seronegative patients (p = 0.000), that is, the distal colon in Chagas patients was, on average, 5.1cm longer. Seropositive female patients presented a mean length of 58.8 (±12.3)cm, and seronegative female patients presented 53.2 (±9.1)cm (p = 0.002). Seropositive male patients had a mean length of 55 (±11.6)cm, and seronegative male patients had 49.9 (±7.8)cm (p = 0.02). Among 191 patients without megacolon and suspected megacolon, the mean length was 56.3 (±11.6)cm in seropositive individuals and 52 (±8.8)cm in seronegative patients (p = 0.003). Among individuals with distal colon >70cm, there were 31 Chagas patients with mean length of 77.9 (±7.1)cm and three seronegative with 71.3 (±1.1)cm (p = 0.000). Among 179 with distal colon <70cm, seropositive individuals had a mean length of 53.6 (±8.8)cm, and seronegative patients had 51.2 (±7.8)cm (p = 0.059). Serological positive women had longer distal colon than men (p = 0.02), whereas the mean length were the same among seronegative individuals (p = 0.16). CONCLUSIONS: In endemic areas of Brazil Central, solitary dolichocolon is a radiological Chagas disease signal.

INTRODUÇÃO: Desde 1970, suspeita-se que o alongamento do retossigmoide pode ocorrer como manifestação isolada da colopatia chagásica. MÉTODOS: Para testar esta hipótese, 210 pacientes soropositivos e 63 soronegativos fizeram enema opaco e as radiografias nas posições ântero-posterior e póstero-anterior foram lidas sem conhecimento dos dados clínicos e sorológicos. O comprimento do cólon distal foi medido com curvímetro, percorrendo-se o eixo central da imagem, do ânus à crista ilíaca. RESULTADOS: O diagnóstico de dolicocólon foi estabelecido em 31 (14,8%) pacientes soropositivos e 3 (4,8%) soronegativos. O comprimento médio nos pacientes soropositivos foi de 57,2 (±12,2)cm, enquanto nos soronegativos foi de 52,1 (±8,8)cm (p=0,000), isto é, os chagásicos apresentaram o cólon distal em média 5,1cm maior. Os indivíduos do sexo feminino soropositivos exibiram comprimento médio de 58,8 (±12,3)cm, e os soronegativos de 53,2 (±9,1)cm, (p=0,002). Nos pacientes do sexo masculino soropositivos, o comprimento médio foi de 55 (±11,6)cm, enquanto nos soronegativos foi de 49,9 (±7,8)cm (p=0,02). Nos 191 pacientes, sem megacólon e suspeitos de megacólon, o comprimento médio foi de 56,3 (±11,6)cm nos soropostivos e 52 (±8,8)cm nos soronegativos (p=0,003). Dos indivíduos com cólon distal >70cm, os 31 chagásicos tiveram comprimento médio de 77,9 (±7,1)cm, enquanto nos três não chagásicos foi de 71,3 (±1,1)cm, (p=0,000). Nos 179 com cólon distal <70cm, os soropositivos tiveram em média 53,6 (±8,8)cm, e os soronegativos 51,2 (±7,8)cm, (p=0,059). Dentre os com sorologia positiva, as mulheres apresentaram cólon distal maior que os homens (p=0,02), enquanto naqueles com sorologia negativa o comprimento médio foi igual (p=0,16). CONCLUSÕES: Nas áreas endêmicas do Brasil Central, o dolicocólon solitário é um sinal radiológico da doença de Chagas.

Stercolith Perforation

A 62-year-old diabetic bed ridden woman, presented to the emergency department with symptoms suggestive of peritonitis. She had been taking oral laxatives and enemas to relieve her chronic constipation for last 6 years. Hard impacted stools and pelvic tenderness were found on digital rectal examination. Her X-ray abdomen showed soft tissue shadows in the colon but there was no gas under the diaphragm on chest X-ray. Sonography found free fluid in pelvis. She was resuscitated, and her hyperglycemia was controlled by use of regular insulin as per sliding scale. Operative findings revealed free fluid in pelvis and very hard faecalomas lying free in peritoneal cavity. There was a 2 x 3 cm perforation at the anterior wall of the recto-sigmoid junction. Peritoneal toilet was carried out followed by Hartmann's procedure. Histopathology of perforation side showed no evidence of malignancy

Fístula colovesical secundaria a la migración de una endoprótesis biliar: reporte de un caso / Colovesical fistula secondary to the migration of a biliary stent: case report

Introducción: la colocación endoscópica de stents para descomprimir una obstrucción biliar es un tratamiento comúnmente utilizado para enfermedades malignas de la vía biliar y para estenosis benignas de la misma. Se han descrito complicaciones inusitadas derivadas de la colocación de endoprótesis biliares, incluyendo la migración. Se presenta un caso clínico con el objetivo de compartir con la comunidad científica una rara complicación y la única publicada, secundaria a la migración de un stent biliar. Caso clínico: mujer de 47 años de edad, con estenosis de ámpula de Vater benigna, a quien se le colocó endoprótesis biliar, con la cual mejoró clínicamente. Posterior a la colocación del stent se le realizó colecistectomía abierta con exploración de vías biliares. Al año y medio posterior a la colocación del stent, la paciente presentó dolor vago en abdomen bajo y disuria; se le practicaron estudios de imagen donde se observó un extremo del stent biliar en colon sigmoides y otro en vejiga. Se realizó intervención quirúrgica encontrando fístula colovesical, la cual se resolvió en un solo tiempo quirúrgico. La paciente fue egresada con resultados satisfactorios.

BACKGROUND: The endoscopic placement of endoprostheses to decompress biliary obstruction is a commonly used treatment for malignant biliary diseases and is also used in the treatment of benign biliary strictures. Unusual complications of endoprosthesis placement have been described and include the migration of the stent. We present a case to share with the scientific community, an unusual complication secondary to the migration of a biliary stent that has not previously been reported to our knowledge. CASE REPORT: We present the case of a 47-year-old female with a diagnosis of benign papillary stenosis. The patient received a biliary endoprosthesis with clinical improvement. Later she underwent open cholecystectomy and common duct exploration. At consultation 18 months later, the patient presents with indistinct lower abdominal pain and dysuria. We performed imaging studies where the biliary stent was observed, partly in the sigmoid colon and partly in the bladder. The patient underwent surgery where a colovesical fistula was found and treated during the same surgical event. The patient was discharged succesfully.

A case of gallstone ileus with an unusual impaction site and spontaneous evacuation.

Gallstone ileus is an unusual cause of colonic obstruction. The formation of a fistula between the gall bladder and the bowel wall may allow a gallstone to enter the intestinal tract. Plain abdominal films, abdominal ultrasound and abdominal computed tomography aid in the diagnosis. Although surgery is the treatment of choice in cases of colonic gallstone ileus, colonoscopic removal of the impacted stone should be attempted. We describe the case of an 85-year-old man who presented with symptoms and signs of large bowel obstruction. Diagnostic evaluation revealed a large gallstone impacted in the sigmoid colon, which is a rather unusual impaction site. Despite our efforts we could not extract the stone endoscopically, mainly due to its large size. Yet, despite its large size, the stone was spontaneously evacuated a few hours later.

Sigmoid colon perforation by ingested Sandorica seed.

This retrospective descriptive study of Sigmoid colon perforation by ingested Sandorica seed in patients who were admitted to Prachomklao Hospital from 1996 to 2000. Nine cases were included in this study. Most cases were elderly with a mean age of 65 years (range 52-78 years). The main symptoms were abdominal pain with generalized peritonitis and severe tenderness at the suprapubic area, ileus and persistent vomiting. In all cases, the diagnosis was made at operation, with removal of the Sandorica seed, closure of the perforation at the rectosigmoid colon with simple suture and proximal transverse loop colostomy. Post-operative complications included two cases of wound infection.

Delayed Colon Perforation after Palliative Treatment for Rectal Carcinoma with Bare Rectal Stent: A Case Report

In order to relieve mechanical obstruction caused by rectal carcinoma, a bare rectal stent was inserted in the sigmoid colon of a 70-year-old female. The proce-dure was successful, and for one month the patient made good progress. She then complained of abdominal pain, however, and plain radiographs of the chest and abdomen revealed the presence of free gas in the ubdiaphragmatic area. Surgical findings showed that a spur at the proximal end of the bare rectal stent had penetrated the rectal mucosal wall. After placing a bare rectal stent for the palliative treatment of colorectal carcinoma, close follow-up to detect possible perforation of the bowel wall is necessary.

Vólvulo del sigmoides / Sigmoid volvulus

Se presenta una revisión bibliográfica del vólvulo de sigmoides, con una puesta al día de las causas más importantes que originan este cuadro y de las distintas alternativas terapéuticas utilizadas hoy en día. Se destaca la importancia y el valor del manejo descompresivo endoscópico realizado en primera instancia el que en manos experimentadas alcanzan cifras de éxito superiores al 80 por ciento. La cirugía juega un rol muy importante, sobre todo en los centros qur no disponen de estas medidas descompresivas, y en los casos en que se encuentra el asa volvulada necrosada. En ellos las técnicas empleadas dependen de la experiencia de los cirujanos de urgencia, pero sigue teniendo gran validez la operación de Hartmann, la que debería ser manejada por todo cirujano de urgencia. Las alternativas técnicas en casos de vólvulo sigmoideo con asa viable son numerosas, pero deben ser adecuadamente seleccionadas dependiendo de las posibles causas de esta patología y del entrenamiento en cirugía coloproctológica del equipo de urgencia

Large intestine obstruction complicated with perforation: a rare manifestation of Schistosoma mansoni infection

The authors report a case of a 25 year old Brazilian man with a history of crampy abdominal pain in the left iliac fossa for 2 weeks, abdominal distention, mucous diarrhea and anorexia. The patient presented signs of hemodynamic instability and a hard mass palpated in the left iliac fossa presented peritoneal irritation. At laparotomy, fecal peritonitis and a punched-out perforation of the midsigmoid colon were found. A left hemicolectomy was performed with terminal colostomy. Specimen examination revealed a thickened rectosigmoid wall, narrow lumen and multiple mucosal polyps. Microscopically, chronic granulomatous colitis with Schistosoma mansoni eggs confirmed the etiology. To the authors'knowledge, this is the first case of obstruction complicated with perforation due to mansoni schistosomiasis reported in the literature.

Divertículo gigante de sigmóide / Giant sigmoid diverticulum

Os autores relatam um caso de divertículo de sigmóide, complicaçao rara da doença diverticular do cólon. Estudam as teorias atuais que explicam sua fisiopatologia e comentam o quadro clínico, com os métodos de diagnóstico e as possibilidades terapêuticas a serem empregadas.

Diverticular disease of colon; Indian variant.

Diverticular disease of colon is a rare entity in our country; true incidence of which is not known. We present three cases of diverticular disease, two with lower gastro-intestinal (GI) hemorrhage and one with sigmoid colon perforation and peritonitis. All three patients underwent emergency surgical treatment. Two patients survived and one died. No further complications were noted on follow up.