Deslocamento espontâneo do núcleo do cristalino para câmara anterior / Spontaneous displacement of the lens nucleus into the anterior chamber

RESUMO Ao longo da vida, o cristalino produz novas fibras dispostas de forma concêntrica, que aumentam seu diâmetro anteroposterior e peso, tornando seu núcleo mais compacto e endurecido. A catarata hipermadura é uma forma de progressão avançada dessa proliferação de fibras, que pode desencadear uma variedade de complicações. A ruptura espontânea da cápsula anterior do cristalino, evoluindo com deslocamento anterior do núcleo, é uma complicação rara e com poucos casos publicados na literatura. Descrevemos o caso de uma paciente do sexo feminino, 68 anos, que apresentou ruptura espontânea da cápsula anterior do cristalino com deslocamento anterior do núcleo em olho esquerdo sem histórico de trauma ocular. A paciente foi submetida à facoemulsificação do cristalino e ao controle da pressão intraocular, evoluindo com melhora do quadro clínico.

ABSTRACT Throughout life, the lens produces new fibers arranged concentrically, which increase its anteroposterior diameter and weight, making its nucleus more compact and hardened. Hypermature cataract is an advanced stage of this fiber proliferation, which can trigger a variety of complications. Spontaneous rupture of the anterior lens capsule evolving with anterior displacement of the nucleus is a rare complication, with few cases published in the literature. We describe the case of a 68-year-old female patient, who presented spontaneous rupture of the anterior lens capsule with anterior displacement of the nucleus in the left eye, without a history of ocular trauma. The patient underwent phacoemulsification and clinical control of intraocular pressure, improving her condition.

An innovative proposal for anophthalmic cavity reconstruction surgery with bone cement: a case report / Proposta inovadora para reconstrução de cavidades anoftálmicas utilizando cimento ósseo: um relato de caso

ABSTRACT We present a patient who underwent evisceration surgery after spontaneous rupture of the ocular globe due to long-data uncontrolled glaucoma, with posterior placement of an orbital implant made of a bone cement compound based on polymethylmethacrylate as alternative materials were not available. Such a compound is characterized by excellent biocompatibility and low cost, which makes it an interesting alternative for treatment. The anophthalmic socket was successfully filled, providing proper esthetic results and favorable conditions for the posterior scleral prosthesis implantation. No complications were observed during 10 months of follow-up. We believe that, in the absence of alternative materials, low-cost materials may be used in emergency settings to repair anophthalmic cavities and provide satisfactory functional and esthetic outcomes.

RESUMO Apresentamos um paciente que foi submetido à cirurgia de evisceração após ruptura espontânea do globo ocular devido a glaucoma não controlado de longa data, com posterior colocação de implante orbital feito de cimento ósseo, composto à base de polimetilmetacrilato, diante da indisponibilidade de materiais alternativos. Tal composto se caracteriza pela excelente biocompatibilidade e baixo custo, o que o torna uma alternativa interessante para o tratamento. A cavidade anoftálmica foi preenchida com sucesso, fornecendo resultados estéticos adequados e condições favoráveis para o implante posterior de prótese escleral. Nenhuma complicação foi observada durante os 10 meses de seguimento. Acredi­tamos que, na ausência de materiais alternativos, materiais de baixo custo podem ser usados em situações emergenciais para preencher cavidades anoftálmicas e prover resultados funcionais e estéticos satisfatórios.

Spontaneous heterotopic triplet pregnancy with a two viable intrauterine embryos and an ectopic one with right tubal rupture / Gravidez heterópica tripla espontânea com dois embriões intrauterinos viáveis e um ectópico com ruptura da tuba uterina direita

Abstract Heterotopic pregnancy (HP) is defined as the simultaneous development of an intra- and an extra uterine gestation. The occurrence of a spontaneous triplet HP is an exceptionally rare medical condition. We report the case of a young woman with spontaneous heterotopic triplets at 8weeks of gestation, with amisdiagnosis of topic twins and acute appendicitis. The ectopic tubal pregnancy was ruptured and a salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed uneventfully. The two healthy babies were delivery by cesarean section at 36 ± 2 weeks of gestation. Heterotopic triplets with ruptured tubal ectopic pregnancy represent a special diagnostic and therapeutic challenge for the obstetrician. A high rate of clinical suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Resumo A gravidez heterotópica é definida como o desenvolvimento simultâneo de uma gestação intra- e extra-uterina. A ocorrência de gravidez tripla heterotópica espontânea é uma condição médica excepcionalmente rara. Relatamos o caso de uma jovem com gravidez tripla espontânea, às 8 semanas de gestação, com um diagnóstico errôneo de gêmeos tópicos e apendicite aguda. A gravidez tubária ectópica estava rota e uma salpingectomia foi realizada por laparotomia. A gravidez intrauterina progrediu sem intercorrências. Os bebês nasceramsaudáveis por cesariana realizada às 36 semanas de gestação.Agravidez de heterotópicos comectopia e rotura tubária é umdesafio diagnóstico e terapêutico.Umalto índice de suspeita e tratamento oportuno por laparotomia ou laparoscopia podem preservar a gestação intrauterina com um resultado bem sucedido da gravidez tópica.

Rotura hepática en gestante residente en gran altura y la utilidad del monitoreo hemodinámico con doppler transesofágico / Hepatic rupture in a pregnant woman resident at high altitude and the usefulness of hemodynamic monitoring with transesophageal Doppler

RESUMEN La rotura hepática es una complicación poco frecuente de la gestación que se asocia a preeclampsia y síndrome HELLP, aumentando la morbimortalidad materna. No hay reportados casos de esta patología en gestantes residentes en altura, a pesar de que se considera a la altura como un factor que influye en la gestación. En este artículo se reporta el caso de una gestante residente de la gran altura, la cual evidenció una rotura hepática con sangrado persistente, siendo reintervenida por cirugía de emergencia oportunamente gracias al monitoreo hemodinámico con doppler transesofágico.

ABSTRACT Hepatic rupture is a rare complication of pregnancy associated with preeclampsia and HELLP syndrome, thus increasing maternal morbidity and mortality. There are no reported cases of this condition in high-altitude dweller pregnant women, even though altitude is considered a factor that influences in pregnancy. In this article the case of a pregnant dweller at high altitude is reported, which revealed hepatic rupture with persistent bleeding, being reoperated by Emergency Surgery appropriately thanks to the hemodynamic monitoring with transesophageal Doppler

Spontaneous rupture of right gastroepiploic artery aneurysm: a rare cause of hemorrhagic shock. case report

ABSTRACT CONTEXT: Aneurysms of the gastroepiploic arteries are seen only rarely. They are usually diagnosed during autopsy or laparotomy in patients with hemodynamic instability. Although the operation to treat this condition is relatively easy, delay in making the diagnosis affects the course of the disease. Case Report: A 57-year-old woman was admitted to the emergency department with abdominal pain and unconsciousness. A computed tomography scan showed extravasation of contrast agent at the headcorpus junction of the pancreas, and the patient underwent exploratory laparotomy under general anesthesia. During laparotomy, aneurysmatic rupture of the right gastroepiploic artery was detected. Control over bleeding was achieved by ligating the right gastroepiploic artery at its origin. The aneurysm was also resected and sent for pathological examination. CONCLUSION: Especially in cases of unidentified shock, splanchnic artery aneurysms should be kept in mind. Moreover, in the light of the data in the literature, the possibility of death should be taken into account seriously and, if feasible, prophylactic aneurysmectomy should be performed.

Hematoma subcapsular hepático roto en síndrome HELLP / Ruptured subscapular liver hematoma in context of HELLP syndrome

Background: Ruptured subscapular liver hematoma in context of HELLP syndrome is a rare complication with high mortality. Clinical presentation is nonspecific: epigastric pain, right upper quadrant pain and shoulder pain, should however provide high index of suspicion. Termination of pregnancy is the only definitive treatment with a beneficial effect on the mother and the fetus. According to the hemodynamic status of the patient, treatment can be conservative through hepatic artery embolization, or surgical management, via contained packing of the bleeding area. Aim: To report seven cases of ruptured subscapular liver hematomas treated in a period of 13 years. Material and Methods: Review of medical records of patients discharged with the diagnosis from 2002 to 2015. Results: We identified seven women aged 30 to 44 years, for a total of 86,858 live births. At presentation, mean gestational age was 36 weeks. Five patients reported epigastric pain and three shoulder pain. All patients met the criteria for HELPP syndrome. All patients were operated on, and packing of the bleeding zone was carried out in six. One patient died. Two newborns died. Conclusions: The features of these patients may help in the management of this uncommon but severe condition.

Ruptura esplênica secundária à infeção por Plasmodium falciparum / Splenic rupture secondary to Plasmodium falciparum infection

A ruptura esplênica é uma complicação possível da malária. É importante pela dificuldade diagnóstica, pois um elevado índice de suspeição é necessário para um diagnóstico atempado. Pode condicionar uma hemorragia intraperitoneal e deve ser considerada no diagnóstico diferencial de quadros de dor abdominal, hipotensão e diminuição do hematócrito. Os autores descrevem o caso de um homem de 59 anos, com ruptura esplênica secundária à malária por Plasmodium falciparum, tendo realizado esplenectomia urgente. Com a apresentação do caso, os autores pretendem chamar a atenção para a necessidade de incluir esta afecção no diagnóstico diferencial dos doentes com malária e hipotensão refractária.

Splenic rupture is a possible complication of malaria. Due to its difficult diagnosis, it is important, because a high level of suspicion is needed for a timely diagnosis. It results in intraperitoneal bleeding and should be considered in the differential diagnosis of abdominal pain, hypotension and low hematocrit. The authors report the case of a 59-year old man with splenic rupture secondary to malarial infection by Plasmodium Falciparum, who was treated with urgent splenectomy. This case is presented to remind the clinicians of include this entity in the differential diagnosis of patients with malaria and refractory hypotension.

Spontaneous rupture of giant hepatic hemangioma

Hemangiomas are the most common benign tumors of the liver, with a prevalence ranging from 0.5 to 7% in necropsies. Tumors larger than 5 cm are called giant hemangiomas. Rupture is a very rare complication, although it is the most severe. We report the case of a 52-year-old patient who presented with a ruptured giant hepatic hemangioma. She was treated with a two-stage surgery, with successful outcome.

Spontaneous coronary artery dissection by intravascular ultrasound in a patient with myocardial infarction

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and sudden cardiac death. The incidence, causes, pathogenesis, and treatment have not been defined clearly, but spontaneous coronary artery dissection should be considered in young patients without major cardiovascular risk factors or in patients in the peripartum period who present with acute coronary syndrome. The treatment is often challenging. Medical treatment is usually considered, and percutaneous coronary intervention or coronary artery bypass surgery may be possible in some patients. We herein report two cases of middle-aged males with myocardial infarction who were treated with percutaneous coronary angioplasty.

Correção da ruptura de cordas tendíneas na insuficiência mitral degenerativa pelo emprego de cordas padronizadas de pericárdio bovino / Surgical repair of chordae tendineae rupture after degenerative valvular regurgitation using standardized bovine pericardium

OBJETIVO: Avaliar, clinicamente e pelo ecodopplercardiograma, o funcionamento da valva mitral em 22 pacientes submetidos à correção do refluxo valvar com substituição das cordas tendíneas nativas por cordas padronizadas de pericárdio bovino. MÉTODOS: Os pacientes apresentavam insuficiência mitral degenerativa. Quatorze (63,6%) pacientes eram do gênero masculino e a idade variou de 19 a 76 anos (média 56,8±13,8 anos). As cordas de pericárdio bovino foram tratadas com glutaraldeído, com reforço de suas extremidades transversais formando um trapézio. RESULTADOS: Um (4,5%) paciente faleceu no pós-operatório imediato em síndrome de baixo débito cardíaco e três (13,6%) no pós-operatório tardio. Uma (4,5%) paciente foi reoperada. As curvas atuariais de sobrevivência livre de óbitos por causa cardiovascular e livres de reoperações para os pacientes que deixaram o hospital (21) demonstraram taxas de 82,0±9,8% e 83,9±10,4%, aos 70 meses de pós-operatório, respectivamente. Dezessete (77,3%) pacientes estão vivos com a própria valva. Dos 17 pacientes vivos com a própria valva 16 (94,1%) estão em classe funcional I. O ecodoppler pós-operatório (média de 41 meses; 4 a 70 meses) demonstrou ausência de regurgitação mitral em 11 (64,7%) pacientes e regurgitação discreta em cinco (29,4%). CONCLUSÃO: A técnica de implante de cordas padronizadas de pericárdio bovino para substituição de cordas tendíneas da valva mitral em pacientes com insuficiência mitral degenerativa demonstrou resultados bastante satisfatórios.

OBJECTIVE: To evaluate clinically and by Doppler Echocardiography 22 patients submitted to mitral valve repair after valvular regurgitation using standardized bovine pericardium chordae. METHODS: The patients had degenerative mitral regurgitation. Fourteen (63.6%) patients were male and the age ranged from 19 to 76 years (mean 56.8 ± 13.8 years). The strings of bovine pericardium treated with glutaraldehyde were reinforced in its transverse ends forming a trapezoid. RESULTS: One patient (4.5%) died in the immediate postoperative period with in low cardiac output syndrome and three (13.6%) in the late postoperative period. One patient (4.5%) was reoperated. The actuarial curves for survival free of death from cardiovascular causes and free from reoperation for patients who left the hospital (21), showed rates of 82.0 ± 9.8% and 83.9 ± 10.4% at 70 months postoperatively, respectively. Seventeen patients (77.3%) are alive with native valves. Of the 17 patients alive with native valves 16 (94.1%) were in functional class I. The Doppler Echocardiography postoperatively (mean 41 months, 4-70 months), showed no mitral regurgitation in 11 (64.7%) patients and mild regurgitation in five (29.4%). CONCLUSION: The technique of standard cords of bovine pericardium implantation to replace chordae tendineae of the mitral valve in patients with degenerative mitral regurgitation showed satisfactory results.

Gastric perforation in the newborn

Gastric perforation in neonates is an uncommon condition. It could be spontaneous but a contributing cause should be sought. To review our experience of treating 8 neonates with gastric perforation over the past 20 years. We reviewed the records of all newborns admitted to our hospital between 1990 and 2010 with regard to gender, age at admission, contributing factors, associated anomalies, site of perforation, type of operation, and outcome. Of the eight neonates, five were female and three male. The average weight was 2130 g. Four babies were premature. Three infants were ventilated for respiratory difficulty. Five patients had associated anomalies. Perforation occurred in the lesser curvature in 4, at the greater curvature in 3, and at the anterior antrum surface in 1. All patients were treated with gastrorrhaphy. Four neonates required additional gastrostomy. Mortality was 75% [6 infants]. Active perinatal management, early treatment of primary pathologies, and protection of the stomach against distension in neonates at risk are essential in the management of neonatal gastric perforation

Reparación artroscópica de las rupturas completas del manguito rotador / Arthroscopic repair of total ruptures of rotator cuff

Introducción: la ruptura del manguito rotador (tendones del subescapular, supraespinoso, infraespinoso y redondo menor) es una enfermedad que afecta el hombro con alta incidencia. La padecen con mayor frecuencia las personas que practican ejercicios repetitivos y existe el antecedente de trauma. El diagnóstico artroscópico con sus ventajas es definitivo y exacto, su correcta interpretación garantiza el éxito de la reparación. Objetivo: evaluar los resultados de las reparaciones artroscópicas con el método de sutura y anclaje, en las rupturas completas del manguito rotador aplicado en el servicio de ortopedia, desde octubre de 2007 hasta abril de 2009. Métodos: se analizaron los resultados en 42 pacientes con rupturas completas del manguito rotador, evaluados con la escala de Constant-Murley. Se realizó un seguimiento promedio de 15,5 meses, con predominio del sexo masculino (69 porciento) y un promedio de edad de 56 años en el momento de la cirugía. Resultados: de los pacientes incluidos, la cirugía se realizó en el miembro dominante en 66,6 porciento. La primera evaluación general de los resultados a los 6 meses del posoperatorio mostró 83,3 porciento de resultados excelentes, buenos y regulares. Los resultados mejoraron con el tiempo, a los 12 meses se obtuvo 97,6 porciento de resultados excelentes, buenos y regulares en la serie. Conclusiones: los resultados de las reparaciones artroscópicas de esta serie de casos son comparables a los reportes que existen en la literatura

Introduction: the rupture of rotator cuff (tendons of the subscapularis, supraspinatus, infraspinatus and teres minor muscles) is a disease affecting the shoulder with a high incidence. It is more frequent present in persons practicing repetitive exercises and there is a background of trauma. Arthroscopic diagnosis with its advantages is definite and exact and the appropriate interpretation of it guarantees the success of repair. Objective: to assess the results of the arthroscopic repairs with the method of suture and anchorage in the total ruptures of rotator cuff applied in the Orthopedics service from October, 2007 to April, 2009. Methods: authors analyzed the results from 42 patients with total ruptures of rotator cuff, assessed using the Constant-Muley scale. A mean follow-up of 15.5 months was carried out with predominance of male sex (69 percent) and an average age of 56 years at surgery. Results: in the patients included surgery was carried out in the dominant limb in the 66.6 percente. The first general assessment of results at 6 postoperative months showed an 83.3 percent of excellent, goods and fair results. With time the results improved, at 12 months it was obtained the 97.6 percent of excellent, good and fair results in the series. Conclusions: the results of arthroscopic repairs of present series of cases are comparable with reports available in literature

Conservative surgical management of mitral insufficiency: an alternative approach / Tratamento cirúrgico conservador da insuficiência mitral: uma abordagem alternativa

Mitral valve insufficiency is frequently the result of elongated or ruptured chordae tendineae. Several techniques have been described for its correction. However, when there is a severe elongation or rupture of the chordae, the most widely accepted treatment option has been valve replacement. The best long-term outcomes observed in conservative surgeries led us to choose this procedure rather than the correction of mitral valve insufficiency. We described three techniques for correction of mitral prolapse due to elongated and/or ruptured chordae tendineae. In addition, we developed mold pre built bovine pericardial chords (Braile-Gregori prosthesis) for chordae replacement. Finally, since 1987, the rigid prosthetic semicircular ring (Gregori-Braile ring) has been consistently used in our centre for correction of the posterior dilation of mitral annulus preferably in its portion close to the posteromedial commissure.

A insuficiência mitral é frequentemente resultado do alongamento ou ruptura das cordas tendíneas. Várias técnicas foram descritas para sua correção. Entretanto, quando o comprometimento das cordas é mais intenso, a substituição valvar tem sido mais usualmente empregada. Os bons resultados a longo prazo observados na cirurgia conservadora têm nos levado a eleger esse procedimento como prioridade. Três técnicas foram por nós desenvolvidas para correção de alongamento e/ou ruptura de cordas tendíneas. Além disso, desenvolvemos uma prótese de pericárdio bovino para a substituição de cordas (prótese Braile-Gregori). Finalmente, desde 1987 empregamos o anel rígido semicircular (anel Gregori-Braile) para a correção do alongamento posterior do anel mitral, com ênfase na sua porção junto à comissura póstero-medial.

Iatrogenic neonatal bladder perforation

Neonatal bladder rupture is rare as a complication of bladder obstruction due to abnormal anatomy or iatrogenic causes. The present study describes the case of a 3-day-old infant with ascites due to bladder perforation secondary probably to manual decompression of the bladder. The infant underwent successful surgical repair of the perforation

Spontaneous rupture of a giant hepatic hemangioma- sequential management with transcatheter arterial embolization and resection

Hemangioma is the most common benign tumor of liver and is often asymptomatic. Spontaneous rupture is rare but has a catastrophic outcome if not promptly managed. Emergent hepatic resection has been the treatment of choice but has high operative mortality. Preoperative transcatheter arterial embolization [TAE] can significantly improve outcome in such patients. We report a case of spontaneous rupture of giant hepatic hemangioma that presented with abdominal pain and shock due to hemoperitoneum. Patient was successfully managed by TAE, followed by tumor resection. TAE is an effective procedure in symptomatic hemangiomas, and should be considered in such high risk patients prior to surgery

Neonatal bladder rupture.

Neonatal bladder rupture is rare as a complication of bladder obstruction due to abnormal anatomy or iatrogenic cause such as umbilical catheterization. The present study describes the case of a 27-day old infant with ascites due to bladder perforation secondary to bladder wall necrosis as a result of severe urinary tract infection. The baby was treated aggressively with antibiotics and underwent successful surgical repair of the perforation.

Surgical management of spontaneous ruptured hepatocellular adenoma

AIMS: Spontaneous ruptured hepatocellular adenoma (SRHA) is a rare life-threatening condition that may require surgical treatment to control hemorrhaging and also stabilize the patient. We report a series of emergency surgeries performed at our institution for this condition. METHODS: We reviewed medical records and radiology files of 28 patients (from 1989 to 2006) with a proven diagnosis of hepatocellular adenoma (HA). Three (10.7 percent) of 28 patients had spontaneous ruptured hepatocellular adenoma, two of which were associated with intrahepatic hemorrhage while one had intraperitoneal bleeding. Two patients were female and one was male. Both female patients had a background history of oral contraceptive use. Sudden abdominal pain associated with hemodynamic instability occurred in all patients who suffered from spontaneous ruptured hepatocellular adenoma. The mean age was 41.6 years old. The preoperative assessment included liver function tests, ultrasonography and computed tomography. RESULTS: The surgical approaches were as follows: right hemihepatectomy for controlling intraperitoneal bleeding, and right extended hepatectomy and non-anatomic resection of the liver for intrahepatic hemorrhage. There were no deaths, and the postoperative complications were bile leakage and wound infection (re-operation), as well as intraperitoneal abscess (re-operation) and pleural effusion. CONCLUSION: Spontaneous ruptured hepatocellular adenoma may be treated by surgery for controlling hemorrhages and stabilizing the patient, and the decision to operate depends upon both the patient's condition and the expertise of the surgical team.

Spontaneous splenic rupture due to dengue fever: report of two cases

Dengue is a febrile illness caused by Flavivírus and mainly transmitted by the mosquito Aedes aegypiti which have been a serious epidemic in Rio de Janeiro. In most of cases it was a self limited disease. We report two cases of a serious and rare complication of this viral infection.