Malrotación intestinal en el adulto: cirugía de Ladd laparoscópica / Intestinal Malrotation in Adults: laparoscopic Ladd's Surgery

Las malrotaciones por bandas de Ladd son un subtipo de anormalidades de la embriogénesis consistentes en prolongaciones fibrosas, producto de una fijación anómala del mesenterio. Se extienden desde el ciego mal rotado hacia el retroperitoneo, pudiendo producir compresión extrínseca del duodeno. En el 90% de los casos la presentación clínica tiene lugar dentro del primer año de vida como un cuadro agudo, en forma de oclusión duodenal o vólvulo de intestino delgado con la consecuente isquemia de este o hernia interna. En la edad adulta, las formas de presentación son menos específicas. Los métodos de referencia ("gold standard") utilizados para el diagnóstico son la seriada gastroduodenal y la tomografía computarizada. El tratamiento quirúrgico consiste en la cirugía de Ladd, cuyo abordaje convencional fue descripto en 1936 por William Ladd. Presentamos el caso de un paciente adulto con un cuadro oclusivo, causado por dicha anomalía, diagnosticado de forma oportuna y resuelto de manera segura por vía laparoscópica. (AU)

Ladd's band malrotations are a subtype of abnormalities of embryogenesis consisting of fibrous extensions, product of abnormal fixation of the mesentery, that goes from the poorly rotated cecum towards the retroperitoneum, which can cause extrinsic compression of the duodenum. In 90% of cases, the clinical presentation takes place within the first year of life, as an acute condition, like duodenal occlusion or small bowel volvulus with its consequent ischemia or internal hernia. In adulthood, the forms of presentation are less specific. The gold standard methods used for diagnosis are gastroduodenal series and computed tomography. Surgical treatment consists of Ladd's surgery, whose conventional approach was described in 1936 by William Ladd. We present ta case of an adult patient with an occlusive presentation, given by this anomaly, diagnosed in a timely manner and safely resolved by laparoscopic approach. (AU)

Respiratory distress and tracheal deviation secondary to sigmoid volvulus / Dificultad respiratoria y desviación traqueal secundaria a vólvulo sigmoideo ­ Un reporte de caso

INTRODUCTION: The trachea is a semiflexible tube of 1.5 to 2 cm in width and 10 to 13 cm in length. Its deviation might be caused by not only diverse thoracic but also abdominal pathologies, which may compromise the airway. We present a case of a severe tracheal deviation due to an abdominal pathology causing displacement of mediastinal structures. CLINICAL CASE: A 78-year-old woman presents with difficulty breathing. History of chronic bedridden and frequently constipated, last stool 5 days prior. On physical examination, cachectic complexion, dry mucous membranes, breathing superficially with scarce wheezing, SatO2 82% on room air. Abdomen distended with an absence of bowel sounds. Chest x-rays show severe tracheal deviation and abdominal x-ray with coffee bean sign. A laparotomy evidences a large sigmoid volvulus. A sigmoidectomy and descending colon colostomy is performed. Room air oxygen saturation improved after extubation to 96%.CONCLUSION: Desaturation and tracheal deviation were caused by a large sigmoid volvulus. Although these pathologies were thoracic, clinicians should suspect different underlying pathologies, in this case, abdominal

INTRODUCCIÓN: La tráquea es un tubo semiflexible de 1-5 a 2 cm de ancho y 10 a 13 cm de longitud. Puede presentar desviaciones en su trayecto, no solo por patologías torácicas, sino también abdominales, las cuales pueden comprometer la vía aérea. Presentamos el caso de una desviación severa de la tráquea por una patología abdominal que ocasionó desplazamiento de las estructuras mediastinales. REPORTE DE CASO: Mujer de 78 años que se presenta por dificultad respiratoria. Antecedente de postramiento crónico en cama y estreñimiento frecuente, con última deposición 5 días previos. En la exploración física presenta complexión caquéctica, mucosas secas, respiración superficial con sibilancias, saturando 82% al aire ambiente. Abdomen distendido con ausencia de ruidos intestinales. Radiografía torácica muestra desviación traqueal severa y la radiografía abdominal muestra signo del grano de café. En el abordaje por laparotomía se evidencia un vólvulo sigmoideo grande. Se realizó sigmoidectomía y colostomía del colon descendiente. La saturación al aire ambiente mejoró después de la extubación a 96%. CONCLUSIÓN: La desaturación y desviación traqueal fueron causadas por un vólvulo sigmoideo grande. Aunque estas patologías eran torácicas, el clínico debe sospechar diferentes patologías de base, como en este caso, abdominales.

Elective laparoscopic sigmoidectomy with preservation of the superior rectal artery prior to endoscopic decompression in sigmoid volvulus

Sigmoid volvulus is a frequent cause of intestinal obstruction. Its management has evolved with the use of laparoscopic surgery, achieving an elective sigmoid resection with anastomosis after a flexible endoscopic detorsion. A female patient was admitted to the emergency room with abdominal pain, distention, and constipation. The abdominal computed tomography showed a whirled sigmoid mesentery in addition to dilated sigmoid loops, and coffee bean sign. The patient successfully underwent a flexible endoscopic detorsion and was scheduled for elective sigmoid colectomy with rectal superior artery preservation and primary anastomosis. During the sigmoid resection, the superior rectal artery preservation is related to a better prognostic, with less bleeding, anastomotic leakage, and hospital stay. Currently, there are few reports of the laparoscopic preservation of the superior rectal artery in patients with sigmoid volvulus. (AU)

Vólvulo de intestino medio: a propósito de dos casos / Middle intestine volvulus: on the purpose of two cases / Volvulus do intestino médio: com propósito de dois casos

La malrotación intestinal es un espectro de malformaciones, que incluye una gran variedad de alteraciones en el proceso de rotación y fijación del intestino. La ausencia completa de rotación intestinal, uno de los tipos de malrotación intestinal más frecuentes, puede presentarse como hallazgo asintomático o manifestarse clínicamente por un vólvulo del intestino medio. Sin embargo, incluso entre aquellos que se presentan con vólvulo del intestino medio, la clínica puede ser muy diferente, según el grado de isquemia y eventual necrosis intestinal. Se presentan dos casos clínicos de malrotación intestinal con vólvulo del intestino medio con presentaciones, imágenes, tratamientos y evoluciones muy disímiles. Se analizan los mismos a la luz de una revisión bibliográfica relevante al tema tratado, se sacan aprendizajes del manejo realizado y la evolución que presentaron, y se enfatizan los elementos de mayor jerarquía para optimizar el manejo de estos pacientes.

Intestinal malrotation is a spectrum of malformations that includes a great variety of alterations in the rotation and fixation process of the intestines. The total absence of intestinal rotation, one of the most frequents types of intestinal malrotation could present as an asymptomatic find or appear clinically as a midgut volvulus. However, even those that appear as midgut volvulus, could show quite different signs and symptoms according to the degree of ischemic insult and possible intestinal necrosis. Two clinical cases of intestinal malrotation with midgut volvulus with quite different presentations, images, treatments, and evolutions, are informed. The two cases are analyzed under a relevant bibliographic revision, knowledge is derived from the carried-out management and evolution, and elements for the future optimization of management are underlined.

A má rotação intestinal é um espectro de malformações, que inclui uma grande variedade de alterações no processo de rotação e fixação do intestino. A ausência completa de rotação intestinal, um dos tipos mais comuns de má rotação intestinal, pode se apresentar como um achado assintomático ou manifestar-se clinicamente como um volvo de intestino médio. Porém, mesmo entre aqueles que apresentam volvo de intestino médio, os sintomas podem ser muito diferentes, dependendo do grau de isquemia e eventual necrose intestinal. Dois casos clínicos de má rotação intestinal com volvo de intestino médio são apresentados com apresentações, imagens, tratamentos e evoluções muito diferentes. São analisados ​​à luz de uma revisão bibliográfica pertinente ao tema em questão, lições aprendidas com o manejo realizado e a evolução que apresentaram, e os elementos de maior hierarquia são enfatizados para otimizar o manejo desses pacientes.

Signo del remolino: cirugía de urgencia o falacia ad populum / Whirpool sign: emergency surgery or Falacia ad populum

Introducción: Las pruebas de diagnóstico por imagen se han convertido en una pieza crucial en el diagnóstico del abdomen agudo en la urgencia, sin embargo, la conducta médica deberá basarse en los hallazgos iconográficos contextualizados. El signo tomográfico del remolino constituye un paradigma por su asociación con el vólvulo intestinal. Objetivos: Registrar pacientes con diagnóstico de abdomen agudo en busca del "signo del remolino" en la tomografía computada e identificar quiénes requirieron intervención quirúrgica. Métodos: Estudio analítico de corte transversal evaluándose 115 tomografías computadas de abdomen agudo obstructivo en búsqueda del signo del remolino. Resultados: 15 tomografías fueron excluidas por tratarse de estudios solicitados en posoperatorios. El signo del remolino se presentó en el 5%. Los diagnósticos fueron de mal rotación intestinal (2%), vólvulo de intestino delgado (1%), vólvulo de sigma (1%) y enterocolitis (1%). Sólo el 60% de los pacientes requirieron cirugía. Discusión: La presencia del signo del remolino no siempre obedece a una resolución quirúrgica. No es patognomónico de una sola entidad puntual, pudiendo representar un hallazgo en el contexto de otra patología aguda, por lo que se debería reconocer sus variantes para instaurar el tratamiento adecuado, sea quirúrgico o médico.

Introduction: The imaging test have become an important piece on the diagnosis of the acute abdomen in emergency, nevertheless medical conduct should be based on contextualized iconographic findings. The tomographic "whirlpool sign" establishes a surgical paradigm for its association with the bowel volvulus. Objetive: To register patients with diagnosis of acute abdomen looking for the "whirlpool sign" in the computed tomography and identify who needed surgical intervention. Methods: Analytical cross-sectional study. 115 tomographies of acute obstructive abdomen have being evaluated. Results: 15 tomographies were excluded. The prevalence of the whirlpool sign was 5%. Diagnoses were intestinal malrotation (2%), midgut volvulus (1%), sigmoid volvulus (1%) and enterocolitis (1%). Only 60% of the patients required surgery. Discussion: The presence of the "whirlpool sign" not always determines a surgical resolution. It is not a pathognomonic sign of a punctual entity; it could represent an ordinary finding in the context of several pathologies. To apply the correct treatment, surgical or medical, for these patients it was important to recognize "whirlpool sign" variants.

Vólvulo primario de íleon: una rara forma de obstrucción intestinal en el adulto: reporte de caso y revisión de la literatura / Primary volvulus of ileum: A rare form of intestinal obstruction in the adult: case report and literature review

Resumen Antecedentes El vólvulo de intestino delgado se produce por el giro anormal del intestino delgado alrededor del eje de su propio mesenterio, lo cual puede generar obstrucción intestinal, isquemia, infarto o perforación. Caso clínico Paciente masculino de 71 años que cursó con abdomen agudo. Sospechando cuadro de oclusión intestinal, se realizó exploración quirúrgica en la que se encontró como hallazgos vólvulo de intestino delgado en la válvula ileocecal, con isquemia y necrosis de 280 cm de intestino delgado, por lo cual se realizó resección intestinal e ileostomía terminal, preservando 320 cm de intestino delgado viable desde ángulo duodeno-yeyunal. Cursó con una evolución satisfactoria. Discusión El vólvulo de intestino delgado es una entidad infrecuente y una urgencia quirúrgica que amenaza la vida. Se debe sospechar en todos los pacientes que presenten dolor abdominal abrupto y signos de obstrucción intestinal, sin cirugía abdominal previa ni otras causas obvias. El diagnóstico precoz y la intervención quirúrgica inmediata son factores clave asociados con un mejor pronóstico para este grupo de pacientes.

Background The small bowel volvulus is caused by the abnormal rotation of the small intestine around the axis of its own mesentery. This can lead to intestinal obstruction, ischemia, infarction or perforation. Clinical case A 71-year-old male patient with an acute abdominal pain, suspicious for a bowel occlusion, performed a surgical exploration, finding small bowel volvulus at the ileocecal valve level, with necrosis and ischemia of 280 cm of the small intestine, resulting in intestinal resection and terminal ileostomy. Still preserving 320 cm of viable small intestine from the duodenojejunal angle, with a satisfactory evolution. Discussion Small bowel volvulus is an uncommon entity, and a life-threatening surgical emergency, that should be suspected in all patients with abrupt abdominal pain and signs of bowel obstruction, without previous abdominal surgery or other obvious causes. Early diagnosis and immediate surgical intervention are key factors associated with a better prognosis for this group of patients.

Vólvulo del colon transverso / [Tranverse colon volvulus].

The volvulus of the colon is a relatively common cause of colonic obstruction, mainly in the sigmoid colon, less frequent in the caecum, and rarely in the transverse colon. Multidetector tomography (MDCT) is able to establish the diagnosis showing dilated loops of proximal right and transverse colon, which depend on the time scale of evolution, with an abrupt transition site at the splenic flexure and a secondary torsion of the transverse colon mesentery. Volvulus of the transverse requires surgical detorsion in adults. Among the therapeutic options, simple detorsion or detorsion associated with a colopexy are included, but both have high rates of recurrence compared to resection techniques. Surgical resection of the involved segment is required prior to gangrene and perforation. Resection with or without primary anastomosis is the treatment of choice and prevents recurrence. The transverse colon volvulus is a disease of very low frequency and clinical diagnosis may be difficult. The management remains controversial. We stress that although many surgeons will never see a case of transverse colon volvulus, it should be considered as a differential diagnosis of intermittent abdominal pain or acute intestinal obstruction.

Transverse colon volvulus: case report and review of literature

Transverse colon volvulus is an uncommon cause of large bowel obstruction. Clinical presentation is not specific and therefore, diagnosis is usually made by radiological investigation. Plain abdominal radiograph resembles sigmoid volvulus, but gastrograsphin enema in non emergency cases will reveal a more proximal obstruction. Therapy consists of urgent surgery, usually with resection of the twisted transverse colon. We present a case with an overview of the literature

Splenic flexure volvulus presenting with gangrene

Volvulus of the splenic flexure is very rare cause of colonic obstruction constituting 2% of cases of colonic segmental volvulus. Primary splenic flexure volvulus [SFV] is due to congenital absence or laxity of the phrenocolic, gastro colic, and splenocolic ligaments while secondary volvulus is due to other causes including some prior surgery releasing these ligaments. A preoperative diagnosis can be established based on the characteristic radiological findings on plain x-ray abdomen and CT scan. We present a case of SFV in a young man who presented with acute abdominal pain, and distension, and illustrate the usefulness of CT scan, and plain x-ray of the abdomen in making a preoperative diagnosis. Laparotomy revealed a gangrenous SFV, which was resected and primary anastomosis was carried out. Literature is reviewed with regards to predisposing factors, presentation, investigation, and management among the more than 32 cases reported so far

CT Angiographic Demonstration of a Mesenteric Vessel "Whirlpool" in Intestinal Malrotation and Midgut Volvulus: a Case Report

Although the color Doppler ultrasonography diagnosis of intestinal malrotation with midgut volvulus, based on the typical "whirlpool" appearance of the mesenteric vascular structures is well-defined in the peer-reviewed literature, the combination of both the angiographic illustration of these findings and the contemporary state-of-the-art imaging techniques is lacking. We report the digital subtraction angiography and multidetector computed tomography angiography findings of a 37-year-old male with intestinal malrotation.