Primary esophageal diffuse large B-cell lymphoma.

A 76-year-old man presented with dysphagia, epigastric pain and weight loss for the last two months. Heavy sweating was also presented. Past medical conditions included type 2 diabetes. He had no evidence of any immunosupressive disease including HIV infection. Physical examination only revealed low-grade fever. Laboratory data showed leukocytosis. Gastroscopy evidenced a complete esophageal stenosis starting at 30 cm, with a severely friable mucosa of malignant appearance. The results of biopsies were insufficient for diagnosis of malignancy. Computed tomography demonstrated a 10-cm irregular tumor located in the distal and middle thirds of the esophagus, which resulted in narrowing of the lumen. Involving tracheal carina, bronchus, and descending aorta were observed. Perforation signs were also seen. Distant metastases were not found. Empirical treatment with piperacillin/tazobactan was started. A surgical gastrostomy to allows nutritional support was performed. Two other gastroscopies were performed resulting in an inconclusive diagnosis. Finally, flow cytometry performed in samples obtained by endobronchial ultrasound-guided biopsy evidenced prominent clonal B-cell populations consistent with extranodal diffuse large B-cell lymphoma exhibing CD10 expression. A treatment with Rituximab in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) was started. Primary esophageal diffuse large B-cell lymphoma (DLBCL), a variant of non-Hodgkin's lymphoma, accounts for less than 1% of all cases of gastrointestinal lymphomas.

Cardiogenic shock following administration of propofol and fentanyl in a healthy woman: a case report.

INTRODUCTION: Cardiogenic shock is very uncommon in healthy people. The differential diagnosis for patients with acute heart failure in previously healthy hearts includes acute myocardial infarction and myocarditis. However, many drugs can also depress myocardial function. Propofol and fentanyl are frequently used during different medical procedures. The cardiovascular depressive effect of both drugs has been well established, but the development of cardiogenic shock is very rare when these agents are used. CASE PRESENTATION: After a minor surgical intervention, a 32-year-old Caucasian woman with no significant medical history went into sudden hemodynamic deterioration due to acute heart failure. An urgent echocardiogram showed severe biventricular dysfunction and an estimated left ventricular ejection fraction of 20%. Extracorporeal life support and mechanical ventilation were required. Five days later her ventricular function had fully recovered, which allowed the progressive withdrawal of medical treatment. Prior to her hospital discharge, cardiac MRI showed neither edema nor pathological deposits on the delayed contrast enhancement sequences. At her six-month follow-up examination, the patient was asymptomatic and did not require treatment. CONCLUSION: Although there are many causes of cardiogenic shock, the presence of abrupt hemodynamic deterioration and the absence of a clear cause could be related to the use of propofol and fentanyl.

Emergency surgery in chronic intestinal pseudo-obstruction due to mitochondrial neurogastrointestinal encephalomyopathy: case reports.

Chronic intestinal pseudo-obstruction (CIPO) is a syndrome characterized by recurrent clinical episodes of intestinal obstruction in the absence of any mechanical cause occluding the gut. There are multiple causes related to this rare syndrome. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is one of the causes related to primary CIPO. MNGIE is caused by mutations in the gene encoding thymidine phosphorylase. These mutations lead to an accumulation of thymidine and deoxyuridine in blood and tissues of these patients. Toxic levels of these nucleosides induce mitochondrial DNA abnormalities leading to an abnormal intestinal motility.Herein, we described two rare cases of MNGIE syndrome associated with CIPO, which needed surgical treatment for gastrointestinal complications. In one patient, intra-abdominal hypertension and compartment syndrome generated as a result of the colonic distension forced to perform emergency surgery. In the other patient, a perforated duodenal diverticulum was the cause that forced to perform surgery. There is not a definitive treatment for MNGIE syndrome and survival does not exceed 40 years of age. Surgery only should be considered in some selected patients.

[Risk factors in patients older than 70 years with complicated colorectal carcinoma]. / Factores de riesgo en pacientes mayores de 70 años con carcinoma colorrectal complicado.

OBJECTIVE: The aim of this study was to analyze the outcome of patients over 70 years of age who underwent emergency surgery for complicated colorectal carcinoma, as well as to identify the factors that might have some influence on outcome. PATIENTS AND METHOD: A retrospective study of 54 patients older than 70 years who underwent emergency surgery for complicated colorectal cancer (42 with obstruction and 12 with perforation) between 1991 and 2002 was performed. Morbidity and mortality after surgery were studied. To determine prognostic factors of morbidity and mortality a multivariate logistic regression analysis was also performed. RESULTS: Overall and major morbidity rates were 81.5% and 42.6%, respectively. The mortality rate was 27.8%. Multivariate analysis revealed that perioperative transfusion (p = 0.014) was an independent predictive factor of major complications and that a high APACHE II score (p = 0.031) and the presence of perforation proximal to the tumor (p = 0.042) independently predicted mortality. CONCLUSIONS: Emergency surgery for complicated colorectal carcinoma in elderly patients carries elevated morbidity and mortality. The presence of risk factors should be taken into account when choosing the most suitable surgical technique and evaluating the need for intensive postoperative treatment.

Factores de riesgo en pacientes mayores de 70 años con carcinoma colorrectal complicado / Risk factors in patients older than 70 years with complicated colorectal carcinoma

Objetivo. El fin de este estudio fue analizar la evolución clínica de los pacientes mayores de 70 años operados de urgencia por carcinoma colorrectal complicado y, además, evaluar los factores con posible influencia en la evolución clínica. Pacientes y método. Se han revisado retrospectivamente los datos de 54 pacientes mayores de 70 años intervenidos de urgencia por carcinoma colorrectal complicado (42 con obstrucción y 12 con perforación) durante el período 1991-2002. Se estudió la morbimortalidad tras la cirugía y se realizó un análisis de regresión logística multivariable para determinar los factores pronósticos de morbilidad y de mortalidad. Resultados. Las tasas de morbilidad global y mayor, y de mortalidad fueron del 81,5, 42,6 y 27,8%, respectivamente. El análisis multivariable mostró que la transfusión perioperatoria (p = 0,014) fue un factor predictivo independiente de complicación mayor y que un índice APACHE II alto (p = 0,031) y la presencia de perforación a distancia (p = 0,042) fueron factores relacionados con la mortalidad.Conclusiones. La cirugía urgente por carcinoma colorrectal complicado en pacientes de edad avanzada conlleva una elevada morbimortalidad. La presencia de factores de riesgo debería tenerse en cuenta al elegir la técnica quirúrgica más adecuada y al valorar la necesidad de un tratamiento postoperatorio intensivo (AU)

Objective. The aim of this study was to analyze the outcome of patients over 70 years of age who underwent emergency surgery for complicated colorectal carcinoma, as well as to identify the factors that might have some influence on outcome. Patients and method. A retrospective study of 54 patients older than 70 years who underwent emergency surgery for complicated colorectal cancer (42 with obstruction and 12 with perforation) between 1991 and 2002 was performed. Morbidity and mortality after surgery were studied. To determine prognostic factors of morbidity and mortality a multivariate logistic regression analysis was also performed. Results. Overall and major morbidity rates were 81.5% and 42.6%, respectively. The mortality rate was 27.8%. Multivariate analysis revealed that perioperative transfusion (p = 0.014) was an independent predictive factor of major complications and that a high APACHE II score (p = 0.031) and the presence of perforation proximal to the tumor (p = 0.042) independently predicted mortality. Conclusions. Emergency surgery for complicated colorectal carcinoma in elderly patients carries elevated morbidity and mortality. The presence of risk factors should be taken into account when choosing the most suitable surgical technique and evaluating the need for intensive postoperative treatment (AU)

Presentación y evolución clínica de las hernias externas incarceradas en pacientes adultos / Presentation and outcome of incarcerated external hernias in adults

Objetivo. Estudiar la presentación y la evolución clínica de pacientes adultos con hernias externas incarceradas y tratar de identificar los factores que podrían tener algún efecto en su curso evolutivo. Pacientes y método. Se ha revisado retrospectivamente a 230 pacientes adultos intervenidos de urgencia por una hernia externa incarcerada durante el período 1992-2001. Se estudiaron las características de la presentación clínica, el tipo de anestesia, los métodos quirúrgicos, las complicaciones y la mortalidad. También se realizó un análisis univariable para determinar los factores con posible influencia en la evolución clínica. Resultados. Hubo 77 hernias crurales, 70 inguinales, 43 umbilicales y 40 eventraciones. Un total de 74 enfermos (32,2%) acudió con más de 48 h de evolución. En 135 pacientes (58,7%) había enfermedades asociadas significativas. En 140 pacientes (60,9%) se usó anestesia general, en 86 raquianestesia y en 4 anestesia local. Los métodos quirúrgicos más utilizados fueron la reparación anatómica y la hernioplastia sin tensión. En 31 casos (13,5%) fue necesaria una resección intestinal. Las tasas de morbilidad global y mayor y de mortalidad fueron del 37,8, el 10 y el 3,9%, respectivamente. Los factores asociados de manera significativa con una evolución desfavorable fueron una sintomatología prolongada, la hospitalización tardía, la presencia de enfermedades asociadas y un grado ASA alto. Conclusiones. El tratamiento urgente de las hernias externas conlleva una elevada morbimortalidad, por lo que un diagnóstico precoz y la reparación electiva de las hernias no complicadas deberían ser la estrategia terapéutica adecuada en los pacientes adultos (AU)

Objective. The aim of this study was to determine the clinical presentation and outcome of incarcerated external hernias in adults, as well as to identify the factors that might have some influence on outcome. Patients and method. A retrospective study of 230 adult patients who underwent emergency surgical repair of incarcerated external hernias from 1992 to 2001 was performed. The characteristics of clinical presentation, type of anesthesia, surgical procedures, complications and mortality were studied. To determine clinical factors that might have some influence on outcome, an univariate analysis was also performed. Results. There were 77 femoral hernias, 70 inguinal, 43 umbilical and 40 incisional hernias. Seventy-four patients (32.2%) presented after 48 h of symptom onset. Significant associated diseases were found in 135 patients (58.7%). General anesthesia was used in 140 patients (60.9%), spinal anesthesia in 86 patients and local anesthesia in four patients. The most commonly used procedures were anatomic repair and tension-free hernioplasty. Bowel resection was required in 31 patients (13.5%). Overall and major morbidity and mortality were 37.8%, 10% and 3.9%, respectively. Factors that were significantly associated with unfavorable outcome were longer duration of symptoms, late hospitalization, concomitant diseases, and a high ASA class. Conclusions. External hernias produce elevated morbidity and mortality if treatment is undertaken as an emergency. Thus, early diagnosis and elective repair of uncomplicated hernias should be performed in adults (AU)

[Presentation and outcome of incarcerated external hernias in adults]. / Presentación y evolución clínica de las hernias externas incarceradas en pacientes adultos.

OBJECTIVE: The aim of this study was to determine the clinical presentation and outcome of incarcerated external hernias in adults, as well as to identify the factors that might have some influence on outcome. PATIENTS AND METHOD: A retrospective study of 230 adult patients who underwent emergency surgical repair of incarcerated external hernias from 1992 to 2001 was performed. The characteristics of clinical presentation, type of anesthesia, surgical procedures, complications and mortality were studied. To determine clinical factors that might have some influence on outcome, an univariate analysis was also performed. RESULTS: There were 77 femoral hernias, 70 inguinal, 43 umbilical and 40 incisional hernias. Seventy-four patients (32.2%) presented after 48 h of symptom onset. Significant associated diseases were found in 135 patients (58.7%). General anesthesia was used in 140 patients (60.9%), spinal anesthesia in 86 patients and local anesthesia in four patients. The most commonly used procedures were anatomic repair and tension-free hernioplasty. Bowel resection was required in 31 patients (13.5%). Overall and major morbidity and mortality were 37.8%, 10% and 3.9%, respectively. Factors that were significantly associated with unfavorable outcome were longer duration of symptoms, late hospitalization, concomitant diseases, and a high ASA class. CONCLUSIONS: External hernias produce elevated morbidity and mortality if treatment is undertaken as an emergency. Thus, early diagnosis and elective repair of uncomplicated hernias should be performed in adults.