Unexpectedly high corneal flap thickness and ectasia after mechanical LASIK / Espessura inesperadamente alta do flap corneano e ectasia após LASIK mecânico

ABSTRACT LASIK is a refractive surgical procedure in which a corneal flap is created to expose the corneal stromal bed. Preoperative estimation of corneal flap thickness is necessary to calculate the percentage tissue altered in LASIK, an important quantitative risk factor for ectasia. The objective of this study was to assess flap thickness and calculate percentage tissue altered to check if unexpectedly thicker flaps and higher percentage tissue altered could pose as risk factors of ectasia. Four subjects (eight eyes) were submitted to mechanical LASIK in 2009 and 2010. Pre and postoperative clinical and tomographic data were reviewed. Mean preoperative estimated percentage tissue altered was 39.18±1.31%, which was borderline for increased ectasia risk when considering the limit of 40%. However, when considering the postoperatively measured flap thickness, the actual mean percentage tissue altered turned out to be 45.17 ± 4.13%, which was significantly higher than predicted preoperatively (p=0.002). Unexpectedly higher postoperative percentage tissue altered may be responsible for corneal ectasia after mechanical LASIK.

RESUMO A LASIK é um procedimento cirúrgico refrativo, no qual um retalho corneano é criado para expor o leito estromal corneano. A estimativa pré-operatória da espessura do retalho corneano é necessária para calcular o percentual de tecido alterado no LASIK, um importante fator de risco quantitativo para ectasia. O objetivo deste estudo foi avaliar a espessura do retalho e calcular o percentual de tecido alterado para verificar se retalhos inesperadamente mais espessos e percentuais de tecido alterado mais altos poderiam representar fatores de risco de ectasia. Quatro indivíduos (oito olhos) foram submetidos à LASIK mecânica em 2009 e 2010. Dados clínicos e tomográficos pré e pós-operatórios foram revisados. A média de percentual de tecido alterado pré-operatória estimada foi de 39,18±1,31%, limítrofe para risco aumentado de ectasia quando considerado o limite de 40%. No entanto, ao considerar a espessura do retalho medida no pós-operatório, o percentual de tecido alterado médio real foi de 45,17±4,13%, ou seja, significativamente maior do que o previsto no pré-operatório (p=0,002). O percentual de tecido alterado pós-operatóriao inesperadamente mais alto pode ser responsável pela ectasia da córnea após LASIK mecânico.

Belin/Ambrósio Enhanced Ectasia Display in cataract surgery and relation to final visual acuity / Belin/Ambrósio Enhanced Ectasia Display na cirurgia de catarata e sua relação com a acuidade visual final

ABSTRACT Objective To analyze and describe the coefficients found on maximum Ambrósio Relational Thickness-Maximum (ART-Max) and Belin/Ambrósio Enhanced Ectasia Display total deviation (BAD-D) in eyes with normal corneal topography subjected to cataract surgery with premium intraocular lens implantation and correlated these data with final visual acuity. Methods ART-Max and BAD-D data from 103 eyes of patients subjected to implantation of diffractive bifocal intraocular lens, with normal corneal topography who achieved visual acuity of 20/20 or 20/25 without correction after cataract surgery were analyzed. The groups with normal and abnormal values were compared using the chi-square test. Results Thirty-two (31.1%) and 71 (68.9%) eyes presented normal and abnormal ART-Max values, respectively. The difference between these groups was significant (p=0.0002). Fifty-five (53.4%) and 48 (46.6%) eyes had normal and abnormal BAD-D, respectively, and intergroup difference was not significant (p=0.9576). Conclusion Among patients with normal corneal topography who underwent premium intraocular and had good final visual acuity of 20/20 or 20/25, suspicious or abnormal indices of ART-Max and BAD-D were frequent, providing evidence that it possibly should not be a contraindication.

RESUMO Objetivo Analisar e descrever os coeficientes numéricos encontrados nos exames Ambrósio Relational Thickness-Maximum (ART-Max) e desvio total do Belin/Ambrósio Enhanced Ectasia Display (BAD-D) em olhos com topografia normal submetidos ao implante de lente intraocular premium na cirurgia de catarata, correlacionando-os com a acuidade visual final pós-operatória. Métodos Foram analisados os resultados de ART-Max e BAD-D de 103 olhos de pacientes submetidos ao implante de lentes bifocais difrativas, que apresentavam exame topográficos normal e alcançaram acuidade visual 20/20 ou 20/25 sem correção visual no pós-operatório final. Para a análise estatística entre os grupos normais e anormais ou suspeitos, utilizou-se o teste do qui-quadrado. Resultados Foram encontrados 32 (31,1%) olhos com ART-Max normal e 71 (68,9%) com ART-Max suspeito/anormal. A diferença entre os grupos foi significativa (p=0,0002). Quanto ao BAD-D, foram encontrados 55 (53,4%) olhos com resultados normais e 48 (46,6%) com resultados suspeitos/anormais. A diferença entre os grupos não foi significativa (p=0,9576). Conclusão Entre os pacientes com topografia normal submetidos ao implante de lentes premium e que alcançaram acuidade visual 20/20 ou 20/25, os índices suspeitos ou anormais de ART-Max e BAD-D eram frequentes, não se configurando em contraindicação para a realização do implante.

Orthokeratology on patient with ectasic cornea / Ortoceratologia no paciente com córnea ectásica

Abstract A 26-year-old man, single, business student, reveals a ectasic cornea during corneal topography exam. Among some procedures, the patient chose Orthokeratology to do a corneal reshape and got successfully a good visual acuity, going against the most authors guidance.

Resumo Estudante de 26 anos, masculino, estudante de economia, apresentou ao exame topográfico de córneas, ectasia corneal. Dentre todos os procedimentos apresentados, optou pela ortoceratologia para o remodelamento corneal, e obteve sucesso com melhora da acuidade visual, indo contra a orientação da maioria dos autores.

Dolor y distensión abdominal: abordaje diagnóstico a distintas edades / Abdominal pain and distention: diagnostic approach at different ages

Fluctuating abdominal pain and bloating suggest gastrointestinal origin with multiple causes. In adults, patients fulfilling the Rome criteria for irritable bowel syndrome (IBS) have a low probability of neoplasms or intestinal inflammatory diseases. In these patients it is cost effective to request fecal calprotectin and celiac disease serology. Due to the high probability of nocebo effect, the diagnosis of sensitivity to non celiac and food allergies should require a blind rechallenge. It is recommended to evaluate other non ominous diagnostic options in a second stage if there is not good control of symptoms. In adults that do not fulfil the criteria of IBS or in adults older than 50 it is often necessary to request more studies, including endoscopic examinations. In children, abdominal pain and bloating occur frequently in the context of excessive consumption of sugar (including fructose, lactose and sorbitol). In infants it can occur in the context of congenital malformations, infant colics and food allergies. An active search for symptoms and signs of alarm is recommended. In their absence the performance of an endoscopic study is low. The use of celiac disease serology is also recommended, but the use of fecal calprotectin has the limitation that normal values are not present below age 4, so its use is not recommended under that age.

El dolor abdominal y la distensión abdominal fluctuantes sugieren origen gastrointestinal, con múltiples causas. En adultos, los pacientes que cumplen criterios de Roma para Síndrome de Intestino Irritable (SII) tienen una baja probabilidad de neoplasias o enfermedades inflamatorias intestinales (EII). En estos pacientes, es costoefectivo solicitar calprotectina fecal y serología de enfermedad celiaca. Por la alta probabilidad de efecto nocebo, el diagnóstico de sensibilidad al gluten no celiaca (SGNC) y alergias alimentarias debería requerir un rechallenge ciego. Es recomendable evaluar otras opciones diagnósticas no ominosas en una segunda etapa, si no hay buen control sintomático. En adultos que no cumplen criterios de SII o en adultos mayores de 50 años, suele requerirse más cantidad de estudios, incluyendo endoscópicos. En niños, el dolor abdominal y distensión ocurren frecuentemente en el contexto de consumo excesivo de azúcares (incluyendo fructosa, lactosa y sorbitol). En lactantes puede ocurrir también en el contexto de malformaciones congénitas, cólicos del lactante y alergia alimentaria. Se recomienda la búsqueda activa de signos y síntomas de alarma. En su ausencia el rendimiento del estudio endoscópico es bajo. También se recomienda el uso de serología de enfermedad celíaca, pero el uso de calprotectina fecal tiene la limitación de ausencia de valores de normalidad hasta los 4 años, por lo que su uso no se recomienda bajo esa edad.

Ectasia ductal mamaria, una entidad poco frecuente en la edad pediátrica: A propósito de un caso / Duct ectasia, an infrequent condition in childhood: A case report

La secreción sanguínea a través del pezón (telorragia) es un síntoma muy poco frecuente y que genera gran alarma en pediatría por su relación con el carcinoma en la edad adulta. La entidad más frecuente asociada en edades tempranas, de naturaleza benigna y autolimitada, es la ectasia ductal mamaria. Se caracteriza por la dilatación del conducto mamario, fibrosis e inflamación periductal. La etiología es desconocida y multifactorial. Son pocos casos los descritos en la literatura científica. Se presenta a un lactante de 5 meses con telerragia por ectasia ductal mamaria, cuya resolución fue espontánea a las 4 semanas. Nuestro objetivo es facilitar el rápido reconocimiento por parte de los médicos, dar a conocer esta patología tan poco frecuente y, así, evitar estudios y tratamientos agresivos e invasivos innecesarios.

Bloody discharge from the nipple (thelorrhagia) is a rare symptom in childhood and is a cause of great concern due to the association with carcinoma in adults. The most common cause in children is mammary duct ectasia, which is a benign and self-limiting condition. It is characterized by dilatation of the mammary ducts, fibrosis and periductal inflammation. The etiology has not been identified and is multifactorial. Up to date, only isolated case reports have been published. Therefore, we present a review of the literature and we report a case of a fivemonth- old male infant that resolves spontaneously. We aimed to improve physicians’ diagnosis accuracy, the knowledge of this condition and to avoid aggressive studies and treatments.

Dilatação Idiopática do Átrio Direito em Adolescente Assintomático – Relato de Caso / Idiopathic Dilation of the Right Atrium in Asymptomatic Adolescent – Case Report

A dilatação idiopática do átrio direito (AD) é uma condiçãorara, frequentemente assintomática, com tratamentocontroverso, podendo se restringir ao acompanhamentoclínico ou tratamento cirúrgico. Descrevemos aqui um caso deum adolescente com achados ecocardiográficos compatíveiscom essa doença...

Internal Jugular Vein Phlebectasia : A Rare Case of Lateral Neck Swelling.

Internal Jugular vein Phlebectasia (IJP) is a rare disease in which there is a fusiform or saccular dilatation of Internal Jugular vein, usually presenting as a compressible neck mass that becomes prominent on coughing, straining or Valsalva manoeuvre. Colour Doppler is the non invasive diagnostic tool which clinches the diagnosis. It is important to keep this diagnosis in mind in case of lateral neck swellings to avoid invasive investigations and inappropriate treatment as management of asymptomatic case is conservative.

Assessing ectasia susceptibility prior to LASIK: the role of age and residual stromal bed (RSB) in conjunction to Belin-Ambrósio deviation index (BAD-D) / Avaliação de suscetibilidade para ectasia antes de LASIK: o papel da idade e do leito estromal residual em conjunto ao índice Belin-Ambrósio (BAD-D)

Purpose: To compare the ability to detect preoperative ectasia risk among LASIK candidates using classic ERSS (Ectasia Risk Score System) and Pentacam Belin-Ambrósio deviation index (BAD-D), and to test the benefit of a combined approach including BAD-D and clinical data. Methods: A retrospective nonrandomized study involved preoperative LASIK data from 23 post-LASIK ectasia cases and 266 stable-LASIK (follow up > 12 months). Preoperative clinical and Pentacam (Oculus; Wetzlar, Germany) data were obtained from all cases. Mann-Whitney's test was performed to assess differences between groups. Stepwise logistic regression was used for combining parameters.The areas under the Receiver Operating Characteristic (ROC) curves (AUC) were calculated for all parameters and combinations, with pairwise comparisons of AUC (DeLong's method). Results: Statistically significant differences were found for age, residual stromal bed (RSB), central corneal thickness and BAD-D (p<0.001), but not for sphere, cylinder or spherical equivalent (p>0.05). ERSS was 3 or more on 12/23 eyes from the ectasia group (sensitivity = 52.17%) and 48/266 eyes from the stable LASIK group (18% false positive). BAD-D had AUC of 0.931 (95% CI: 0.895 to 0.957), with cut-off of 1.29 (sensitivity = 87%; specificity = 92.1%). Formula combining BAD-D, age and RSB provided 100% sensitivity and 94% specificity, with better AUC (0.989; 95% CI: 0.969 to 0.998) than all individual parameters (p>0.001). Conclusion: BAD-D is more accurate than ERSS. Combining clinical data and BAD-D improved ectasia susceptibility screening. Further validation is necessary. Novel combined functions using other topometric and tomographic parameters should be tested to further enhance accuracy. .

Objetivo: Comparar a capacidade de detectar risco de ectasia no pré-operatório de LASIK usando o clássico ERSS (Ectasia Risk Score System) e índice Belin- Ambrósio (BAD- D) do Pentacam; e para testar o benefício de uma abordagem combinada, incluindo BAD-D e dados clínicos. Métodos: Estudo não randomizado retrospectivo envolveu dados pré-operatórios de LASIK de 23 casos que evoluíram para ectasia pós-LASIK e 266 casos estáveis após LASIK com acompanhamento mínimo de 12 meses. Dados préoperatórios clínicos e do Pentacam (Oculus, Wetzlar, Alemanha) foram obtidos para todos os casos. O teste de Mann-Whitney foi realizado para avaliar as diferenças entre grupos. Regressão logística foi utilizada para combinar parâmetros. As áreas sob as curvas Receiver Operating Characteristic (ROC; AUC) foram calculadas para todos os parâmetros e as combinações. Comparações de pares das AUC foram realizadas com método de DeLong. Resultados: Foram encontradas diferenças estatisticamente significativas para a idade, residual leito estromal (RSB), espessura corneana central e BAD- D (p <0,001), mas não para a grau esférico, cilindro ou equivalente esférico (p > 0,05). ERSS foi de três ou mais em 12/23 olhos do grupo ectasia (sensibilidade = 52,17 %) e 48/ 266 olhos do grupo LASIK estável (18% falso positivo). BAD- D teve AUC de 0,931 (IC 95%: 0,895-0,957), com corte de 1,29 (sensibilidade=87%, especificidade=92,1%). A fórmula que combinou BAD-D, idade e RSB, gerou 100% de sensibilidade e especificidade de 94%, com melhor AUC (0,989, IC 95%: 0,969-0,998) do que todos os parâmetros individuais (p>0,001). Conclusão: BAD-D é mais preciso do que ERSS. Combinações de dados clínicos e os BAD-D melhorou a capacidade de identificação ...

Compression of the Main Pancreatic Duct by the Intrapancreatic-Replaced Common Hepatic Artery

We describe a unique case of a patient who presented with a linear, transverse, and incidentally-detected main pancreatic duct dilatation that was caused by the intrapancreatic-replaced common hepatic artery, detected on the MDCT, MRCP and endoscopic retrograde cholangiopancreatography. We believe this case to be the first of its kind reported in the literature.

Importância da tomografia de córnea para o diagnóstico de ectasia / Importance of anterior segment tomography for the diagnosis of corneal ectasia

OBJETIVO: Utilização da metodologia para interpretação da tomografia de córnea e segmento anterior para a detecção e diagnóstico de ectasia corneana. MÉTODOS: Descrição da interpretação clínica dos índices da tomografia de córnea e segmento anterior (Pentacam High Resolution - Oculus, Wetzlar,Germany); relato de 3 casos, demonstrando a importância da propedêutica no exame complementar, através do Pentacam HR®. CONCLUSÃO: Nossa experiência compatibiliza-se com os relatos de literatura na demonstração do incremento de sensibilidade e especificidade para a detecção precoce de susceptibilidade e diagnóstico de ectasia corneana, utilizando a tomografia de córnea e segmento anterior.

PURPOSE: The methodology currently used for interpretation of the cornea and anterior segment tomography for the diagnosis of corneal ectasia and its susceptibility. METHODS: Description of the methodology and clinical interpretation of corneal and anterior segment tomography indexes; report of three cases demonstrating the importance of this new diagnostic tool (Pentacam HR®) in ophthalmological practice. CONCLUSION: The use of corneal and anterior segment tomography seems to be an effective method to increase the sensitivity and specificity for the diagnosis and early detection of corneal ectasia.

Current diagnosis and management of syringocele: a review

Cowper's syringocele is a rare but an under-diagnosed cystic dilation of the Cowper's ducts and is increasingly being recognized in the adult population. Recent literature suggests that syringoceles be classified based on the configuration of the duct's orifice to the urethra, either open or closed, as this also allows the clinical presentations of 2 syringoceles to be divided, albeit with some overlap. Usually post-void dribbling, hematuria, or urethral discharge indicate open syringocele, while obstructive symptoms are associated with closed syringoceles. As these symptoms are shared by many serious conditions, a working differential diagnosis is critical. Ultrasonography coupled with retro and ante grade urethrography usually suffices to diagnose syringocele, but supplementary procedures - such as cystourethroscopy, computed tomography scan, and magnetic resonance imaging - can prove useful. Conservative observation is first recommended, but persistent symptoms are usually treated with endoscopic marsupialization unless contraindicated. Upon reviewing the literature, this paper addresses the clinical anatomy, classification, presentation, diagnosis, and treatment of syringoceles in further detail.

The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Choledocholithiasis without Common Bile Duct Dilatation / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a reason, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to investigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation. METHODS: A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively. RESULTS: CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications. CONCLUSIONS: EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication.

Pneumosinus dilatans: experiencia clínica y revisión del tema / Pneumosinus dilatans: clinical experience and literature review

Se presentan dos casos clínicos del Servicio de Otorrinolaringología (SORL) del Hospital Barros Luco Trudeau (HBLT) con diagnóstico de Pneumosinus dilatans (PD). El PD es una rara condición, que se presenta como una dilatación anormal de uno o varios senos paranasales (SP) sin evidencia de compromiso óseo ni mucoso, que se asocia a dolor y deformidad facial. La tomografía computada (TC) permite hacer el diagnóstico; el tratamiento es quirúrgico y está orientado a descomprimir el o los SP comprometidos; con lo anterior se logra la erradicación del dolor, pero la deformidad facial persiste.

Two clinical cases with a diagnosis of pneumosinus dilatans (PD) from the Servicio de Otorrinolaringología (SORL) of Hospital Barros Lucos-Trudeau (HBLT) are presented. PD is a rare condition in which an abnormal enlargement of one or several paranasal sinuses (PS) is present, with no evidence of bone or mucosa involvement. It is associated with facial pain and deformity. Diagnosis is based on CT scan; treatment is surgical and it is oriented to decompress the PS involved, eradicating pain but with a persisting facial deformity.

Step by step clinical diagnosis

A 54-year-old woman Para 5 was admitted to the hospital because of increasing abdominal enlargment. She felt well until a year ago, when abdominal distention gradually developed. In abdominal ultrasongraphy a coarse, echogenic liver and ascites was detected, the spleen was enlarged and other intraabdominal organs were normal. Abdominal paraeentesis was performed. Serum-aseites albumin gradient was greater than 1.1 gr/dl [high serum-ascites albumin gradient]. Laboratory-tests for evaluating the etiology of cirrhosis revealed: HBs Ag: Neg, HBc Ab: Neg, Hcv Ab: Neg, Anti HBs: Pos. ASMA [anti smooth muscle antibody]: Neg ANCA [anti neutrophilic cytoplasmic antibody]: Neg ANA [anti nuclear antibody]: Neg AMA [anti mitochondria! Antibody]: Neg SPEP [serum protein electrophoresis]: Normal range The patient had no history of hepatotoxic drug usage. In upper GI endoscopy two columns grade II varicose veins were seen. Based on the history and para clinic evaluation cryptogenic cirrhosis was the most probable diagnosis. The patient underwent medical therapy with furosemide and spironolactone, and in regular follow up amount of ascites was under control. A month ago the amount of ascites increased and several therapeutic paraeentesis were performed. Ascites analysis showed high serum-ascite albumin gradient and negative cytology for malignancy. Ultrasonography reported multiple focuses on peritoneal surface with seeding like appearance, cirrhotic liver, enlarged spleen and massive ascites, normal kidneys and uterus and ovaries.Tumour markers measurement revealed: CEA= 0.3 [Normal range= 0-5 ng/ml] alpha FP= 0.4 [Normal range= 0-10 lU/ml]CA 125- 244 [Normal range- 0-35 lU/ml] Abdominal and pelvic CT scan didn't show any tumoural lesion and no paraaortic lymphadenopathy. Trans vaginal sonography reported normal uterus and ovaries. Further tumour marker analysis revealed: Elevated serum level of CA 125 to 414 lU/ml CA 15 - 3 = 27 [normal = up to 40 lU/ml] CA 19 - 9 = 25 [normal = up to 40 lU/ml]. A week later level of CA 125 decreased to 262. Therefore we obtained fluctuating level of CA 125, normal CT scan and normal level of other tumour markers. We found in papers from other countries in the same situation that they performed laparotomy but they found nothing except cirrhosis [1]. In some articles CA 125 presented as a marker of ascites in patients with liver cirrhosis [2]. Some authors suggested that quantification of CA 125 in peritoneal fluid [PCA125] and serum [SCA125] can differentiate between cancer cases and non cancer disease, and they found that ratio of PCA125 to SCA125 [P/S CA125] was significantly lower in non cancer patients than that in cancer ones. [If the ratio is upper than five the risk of malignancy increased] [3]. We quantified CA125 level simultaneously in peritoneal fluid and serum: PCA125 - 210, SCA125 = 250, P/S CA125 - 0.84. The ratio of 0.84 was predictive of a benign disease. In an overview to our patient, we had one sonography that reported seeding like appearance in peritoneal surface, but in CT scan no lesion was detected. Fluctuating level [increase - decrease] of CA125 and low P/S ratio, normal level of other tumour markers, made us to come to the final step of laparoscopic examination and biopsy to determine whether it is malignant or benign. In laparoscopic examination no cancerous lesion or fibrin deposit or tuberculosis granoluma with normal omentum and cirrhotic liver detected. Multiple biopsies were taken from peritoan beside liver which reported normal [no: 159104]. We came to this conclusion that in cirrhotic patient with ascites the elevated level of CA125 with normal level of other tumour markers and low P/S ratio and no malignant finding in imaging is suggestive of a benign process, as described in other articles. More studies on this matter should be performed in order to prevent the unnecessary laparatomies

Compressão extrínseca da artéria coronária esquerda por dilatação aneurismática do tronco pulmonar em adolescente: involução após oclusão cirúrgica de comunicação interatrial seio venoso e plastia redutora do tronco pulmonar / Extrinsic compression of left main coronary artery from aneurysmal dilation of pulmonary trunk in a adolescent: involution after surgery occlusion of sinus venosus atrial septal defect and pulmonary trunk plasty for reduction

Relatamos o caso de um adolescente encaminhado com o diagnóstico de hipertensão pulmonar. A investigação não invasiva detectou comunicação interatrial seio venoso com sinais de hipertensão pulmonar. No estudo hemodinâmico o diagnóstico foi confirmado, sendo também notada compressão esquerda pelo tronco pulmonar. O paciente foi submetido à oclusão cirúrgica da comunicação interatrial e à plastia redutora do tronco pulmonar. Dois anos após o procedimento, o paciente encontra-se bem, com sinais clínicos e ecocardiográficos de hipertensão pulmonar discreta e sem evidências, também pelo ecocardiograma, de obstrução do tronco da artéria coronária esquerda.

We report the case of an adolescent referred with initial diagnosis of pulmonary hypertension. Non-invasive investigation disclosed a sinus venous atrial septal defect with pulmonary hypertension. The hemodynamic study confirmed diagnosis, and also showed extrinsic compression of left main coronary artery by pulmonary trunk. Surgical closure of the defect in addition to pulmonary trunk plasty were undertaken. Two years after the surgery the patient is well, with clinical signs of mild pulmonary hypertension, and showing no evidence - also on echocardiogram - of left coronary artery trunk obstruction.

Implicancias del diagnóstico antenatal de dilatación ureteral / Prenatal diagnosis of ureteral dilation

Muchos de los hallazgos del diagnóstico antenatal de patología urológica son inespecíficos y sólo nos permiten diferenciar pacientes con un mayor riesgo de infección urinaria o de perder función renal. El hecho de identificar un uréter en la ecografía prenatal es un hallazgo inespecífico, que aún no tenemos claro qué significa y qué pronóstico tiene para nuestros pacientes. A partir de noviembre de 1999, tenemos un protocolo prospectivo para el seguimiento y manejo de pacientes con diagnóstico antenatal de patología urológica. Se revisó en forma retrospectiva los pacientes en que hubo dilatación ureteral en la ecografía prenatal.180 pacientes han sido referidos y seguidos según protocolo. En 21 pacientes (11.7 por ciento) se ha hecho diagnóstico de dilatación ureteral en la ecografía prenatal. Once hombres y 10 mujeres. Los diagnósticos postnatales de estos pacientes fueron: 4 pacientes con doble sistema pieloureteral; 2 pacientes con megauréteres; 1paciente con una cloaca; 5 pacientes con dilataciones transitorias; 2 pacientes con ureterocele en sistemaúnico; 1 paciente con reflujo vesicoureteral en un sistema único y con un riñón multicístico en el contralateral; 1 paciente con valvas de uretra posterior y 5 pacientes con obstrucción pieloureteral. Un total de 13 pacientes de los 21 requirieron cirugía (62por ciento) y 8 se manejaron médicamente (38.09 por ciento).El hecho de identificar el uréter dilatado en la ecografía prenatal nos permite identificar una población prenatal de riesgo, ya que un 57,1 por ciento de nuestros pacientes requirieron de cirugía. Llama la atención que 5 pacientes en que se vio el uréter dilatado en la ecografía prenatal, terminaron operándose de obstrucción pieloureteral. Esto apoya la hipótesis de que estas obstrucciones sean secundarias a dilataciones ureterales prenatales. El consejo prenatal tiene que ser dado con cautela y por gente con experiencia, ya que a pesar de existir un riesgo elevado de cirugía...

Prenatal diagnosis is usually non specific and only allows for early detection of patients with a higher risk of developing urinary tract infections or loss of renal function. The identification of the ureter in a prenatal ultrasound is a nonspecific finding. The relevance of this is unknown. A prospective protocol for the management and follow up of patients with antenatal diagnosis of urologicmal formations was started in 1999. We retrospectively review our patients who presented a ureteral dilatation in the antenatal ultrasound.180 patients were referred and follow up was carried out according to protocol. 21 patients (11.7 percent) had ureteral dilatation on the prenatal ultrasound, 11 male and 10 female. The following post natal diagnoses were registered: 4 patients had a duplex kidney, 2 patients had megaureter, 1 patient had a cloaca, 5 patients had transitory dilatations, 2 patients had ureterocele in an single system, 1 patient had VUR in a single system and a contralateral muticystic kidney, 1 patient had posterior urethral valves, and 5 patients had ureteropelvic obstruction.13 of 21 patients required surgery (62 percent), the other 8 required only prophylaxis and follow up (38.09 percent). Being able to identify a dilated ureter in an prenatal ultrasound allowed us to define a high risk group, in which 62 percent required surgery. Of the patients in this group, it is noteworthy that 5 patients in whom a dilated ureter was visualized were operated on for ureteropelvic obstruction. This fact supports the idea that obstructions are secondary to antenatal ureteral dilations. Antenatal advice should be given carefully and by experienced personnel because, although there was a high percentage of surgery in this group, there was also a group of patients that only required antibiotics prophylaxis and image monitoring.