Enfermedad multianeurismática: a propósito de un caso / Multi-aneurysmal disease: a case report

Resumen Introducción: La enfermedad multianeurismática es una entidad patológica poco conocida, la cual presenta diversas etiologías, por lo que su localización, morfología y formas de presentación varían de un caso a otro. Caso clínico: Mujer de 51 años dislipémica. Acude por epigastralgia. Se realiza TC abdominal con resultados de hematoma retroperitoneal y aneurisma en arteria pancreática duodenal. Se practica cirugía urgente para evacuación del hematoma sin encontrarse más hallazgos. Durante el ingreso presenta crisis hipertensivas y se realiza nuevo AngioTC donde se visualizan múltiples lesiones en distintas arterias viscerales con posibilidad diagnóstica de vasculitis. Se decide no intervención en el momento actual y estudio de filiación. Discusión: La enfermedad multianeurismática es una entidad poco común, cuya etiología se determina de acuerdo con su correlación clínica e histopatológica con diversas posibles causas; sin embargo, establecer un diagnóstico en donde el cuadro clínico coincida al 100%, es un desafío. Es muy frecuente la afectación de las arterias viscerales a diferencia de los aneurismas de origen ateroesclerótico. El tratamiento quirúrgico es seguro y deberá iniciarse en los segmentos que estén causando la sintomatología. El tratamiento endovascular es menos invasivo siendo la técnica de elección en pacientes con elevada comorbilidad y en los casos de cirugía complicada con rotura.

Introduction: Multiple artery aneurysms are a rare pathological condition which may be caused by different etiologies. Therefore, its location, morphology and clinical presentation may vary in a case to case basis. Case report: A 51-year-old woman, prior history of dyslipedemia presents with upper abdominal pain. Abdominal tomographic scans showed aneurysm of the pancreaticduodenal artery and retroperitoneal hematoma. Emergent surgical evacuation of the hematoma was performed, with no other findings. In the postoperative period, the patient suffers hypertensive crisis and a new tomographic scan is conducted observing multiple dilations in different visceral arteries. The patient is treated conservatively and is being studied for a possible vasculitis. Discussion: Multi-aneurysmatic artery disease is a very rare entity, its etiology is determined by clinical and histopathological correlation. Although establishing a diagnosis in which the clinical presentation completely corresponds, is a real challenge. Unlike degenerative aneurysms due to atherosclerosis, multi-aneurysmatic disease commonly involves visceral arteries. Open surgery is considered safe treatment option and should be established in the segments causing symptoms. Endovascular treatment is less invasive, being the technique of choice in patients with high comorbidity and in cases of complicated surgery with rupture.

Effect of protective solutions and hydroxyethyl starch in the attenuation of the injuries of ischemia and reperfusion of splanchnic organs

PURPOSE: Vogt´s antioxidant solution (red blood cells, Ringer's solution, sodium bicarbonate, mannitol, allopurinol and 50% glucose) or its modification including hydroxyethyl starch (HES) were tested for the prevention of splanchnic artery occlusion shock. METHODS: Seventy rats were distributed in treatment (3), control (1), and sham (3) groups. Ischemia and reperfusion were induced by celiac, superior mesenteric and inferior mesenteric arteries occlusion for 40 min, followed by 60 min reperfusion or sham procedures. Controls received saline, both treatment and sham groups received the Vogt's solution, modified Vogt's solution (replacing Ringer's solution by HES), or HES. Mean arterial blood pressure (MABP), ileal malondialdehyde (MDA) and plasmatic MDA were determined, and a histologic grading system was used. RESULTS: At reperfusion, MABP dropped in all I/R groups. Only HES treatment was able to restore final MABP to the levels of sham groups. Plasmatic MDA did not show differences between groups. Ileum MDA was significantly higher in the control and treatment groups as compared to the sham group. Histology ranking was higher in the only in control group. CONCLUSIONS: Hydroxyethyl starch was able to prevent hemodynamic shock but not intestinal lesions. Both treatments with Vogt's solutions did not show any improvement. .

Very short cycles of postconditioning have no protective effect against reperfusion injury. Experimental study in rats / Ciclos muito curtos de pós-condicionamento não protegem contra lesão de reperfusão. Estudo experimental em ratos

Introduction: Ischemic postconditioning has been recognized as effective in the prevention of reperfusion injury in situations of ischemia and reperfusion in various organs and tissues. However, it remains unclear what would be the best way to accomplish it, since studies show great variation in the method of their application. Objective: To assess the protective effect of ischemic postconditioning on ischemia and reperfusion in rats undergoing five alternating cycles of reperfusion and ischemia of 30 seconds each one. Methods: We studied 25 Wistar rats distributed in three groups: group A (10 rats), which underwent mesenteric ischemia (30 minutes) and reperfusion (60 minutes); Group B (10 rats), undergoing ischemia (30 minutes) and reperfusion (60 minutes), intercalated by postconditioning (5 alternating cycles of reperfusion and ischemia of 30 seconds each one); and group C - SHAM (5 rats), undergoing only laparotomy and manipulation of mesenteric artery. All animals underwent resection of an ileum segment for histological analysis. Results: The mean lesions degree according to Chiu et al. were: group A, 2.77, group B, 2.67 and group C, 0.12. There was no difference between groups A and B (P>0.05). Conclusion: Ischemic postconditioning was not able to minimize or prevent the intestinal tissue injury in rats undergoing ischemia and reperfusion process when used five cycles lasting 30 seconds each one. .

Introdução: O pós-condicionamento isquêmico tem sido reconhecido como eficaz na prevenção das lesões de reperfusão em situações de isquemia e reperfusão em vários órgãos e tecidos. Entretanto, não está ainda claro qual seria a melhor maneira de realizá-lo, já que as publicações mostram grande variação de método no seu emprego. Objetivo: Avaliar o efeito protetor do pós-condicionamento isquêmico na isquemia e reperfusão intestinal em ratos, através de cinco ciclos alternados de 30 segundos de isquemia e 30 segundos de reperfusão. Métodos: Foram estudados 25 ratos Wistar, distribuídos em três grupos: grupo A (10 ratos), em que se realizou isquemia (30 minutos) e reperfusão (60 minutos) mesentérica; grupo B (10 ratos), isquemia e reperfusão, seguidos de pós-condicionamento isquêmico com 5 ciclos alternados de reperfusão e reoclusão, de 30 segundos cada; e grupo C (5 ratos), controle (SHAM). Ao final, ressecou-se um segmento do intestino delgado para análise histológica. Avaliaram-se os resultados pela classificação de Chiu et al. e procedeu-se ao tratamento estatístico. Resultados: As médias dos graus de lesão tecidual segundo a classificação de Chiu et al. foram: no grupo A, 2,77; no grupo B, 2,67; e no grupo C, 0,12. A diferença entre o resultado do grupo A com o resultado do grupo B não teve significância estatística (P>0,05). Conclusão: O pós-condicionamento isquêmico não foi capaz de minimizar ou prevenir a lesão tecidual intestinal de ratos submetidos ao processo de isquemia e reperfusão mesentérica quando utilizados cinco ciclos com duração de 30 segundos cada. .

Isquemia mesentérica aguda: experiencia de 10 años / Acute mesenteric ischemia: 10 years experience

La isquemia mesentérica aguda (IMA) es una emergencia vascular poco frecuente, alrededor de 1 a 4 casos por 1000 operaciones abdominales de urgencia o 9 por cada 1000 admisiones hospitalarias. El síndrome de isquemia mesentérica representa la causa más frecuente de isquemia intestinal e incluye procesos de embolía, trombosis del eje arterial mesentérico superior, trombosis del eje venoso mesentérico superior e isquemia mesentérica no oclusiva (IMNO). La primera aproximación en el diagnóstico y tratamiento, en la mayoría de nuestros hospitales, es realizada por el cirujano general del servicio de emergencia. Constituida la necrosis intestinal, las manifestaciones clínicas de abdomen agudo y el compromiso hemodinámico y séptico que acompañan al infarto visceral, son señales inequívocas de un proceso muy avanzado y que probablemente termine con la vida del paciente. El diagnóstico etiológico preciso varía según los métodos de estudio disponibles (TAC abdomen, ecografía dupplex, angiografía). La angiografía es el método diagnóstico de elección, pero el TAC y ECO DUPLEX también son métodos diagnósticos importantes en trombosis venosa mesentérica, a veces con mejor rendimiento

Experience with the management of mesenteric aneurysms

Mesenteric artery aneurysms represent a rare but very interesting clinical entity. Despite their rarity they comprise a challenging vascular problem as regards diagnosis and treatment. We have managed six mesenteric anuerysms, four involving the SMA and the other two involving the IMA. There were five males and one female patient. The presentation included acute abdominal pain in four cases, haematemesis in one case and abdominal mass in the remaining aneurysm. Surgical treatment was carried out in all six including ligation of the two IMA aneurysms, as well as two SMA aneurysms. Reconstruction was performed in the remaining two SMA aneurysms. Surprisingly, no complications [apart from ARDS in one patient] were recorded in all six cases

Disecciones aorticas: cirugía indirecta de las complicaciones isquémicas / Aortic dissections: indirect surgery in ischemic complications

Objetivo: exponer nuestra experiencia en la revascularización indirecta de las complicaciones isquémicas derivadas de disecciones aórticas y evaluación de la sobrevida de nuestros pacientes como un parámetro aproximado del resultado obtenido. Material y métodos: se conformó una serie de 22 pacientes intervenidos entre 1978 y 1998 por complicaciones isquémicas en región única y 8 con más de una región comprometida. Cuatro disecciones tipo A y 18 tipo B. Se clasificaron las disecciones mediante arteriografía por cateterismo axilar o femoral y a todos se les practicó estudio tomográfico. Resultados: la mortalidad operatoria (primer mes) fue de 22,7 por ciento ñ 8,9. La sobrevida acumulada fue de 77,3 por ciento ñ 8,9 al primer mes, disminuyendo a 72,7 por ciento ñ 9,5 al segundo, a 68,2 popr ciento ñ 9,9 al tercero, resultando de 55,7 por ciento ñ 11,7 a los 24 meses. La sobrevida en 5 pacientes con isquemia solamente en miembros inferiores fue del 100 por ciento operatoria y 75 por ciento ñ 22 a 24 meses, mientras que en pacientes con isquemia mesentérica y/o renal fue 71 por ciento ñ 11 y 53 por ciento ñ 12, respectivamente (p=ns). Los pacientes con insuficiencia renal recuperaron la función. No se realizó ninguna amputación de miembro inferior. Conclusión: la tasa de mortalidad operatoria con cirugía indirecta (22,7 por ciento; 4,9 por ciento a 40,5 por ciento según intervalo de confianza 95 por ciento) resultó menor a la cirugía directa según bibliografía consultada (50 por ciento; p<0,05)

Mesenteric vasculopathy in intestinal tuberculosis.

BACKGROUND: Involvement of mesenteric vessels in intestinal tuberculosis and its role in the pathogenesis of the intestinal changes have not been studied histologically. AIM: To study mesenteric vessels in patients undergoing surgery for complications of intestinal tuberculosis. METHODS: Resected intestinal specimens from 68 patients presenting with intestinal perforation and intestinal obstruction were examined; involvement of the major mesenteric vessels was evaluated. RESULTS: Granulomas were seen in the vessel wall in one case and near the vessel wall in 11 cases, intraluminal thrombi were seen in 23 cases, and subintimal fibrosis in nine cases. Perivascular cuffing was seen in intramural and subserosal vessels in ten cases. CONCLUSIONS: Changes in the vessel wall may lead to gut ischemia, which may contribute to the development of strictures and stercoral perforation in intestinal tuberculosis.