Gallstone Ileus: A Rare Cause of Mechanical Bowel Obstruction.

A gallstone ileus is a rare cause of mechanical bowel obstruction, accounting for 1% to 4% of all cases. Twenty-five percent of the patients are 65 years of age or older and often present previous significant medical conditions. The authors report the case of an 87-year-old male patient, admitted with the diagnosis of community-acquired pneumonia, who later developed frequent episodes of biliary vomiting, intermittent constipation, and abdominal distension. Abdominal imaging (ultrasound and computed tomography (CT)) showed evidence of a localized inflammatory process in a small bowel loop but excluded vesicular lithiasis. After a failure in the medical approach with antibiotics, an exploratory laparotomy was performed, identifying the intestinal occlusion area, followed by an enterolithotomy at the specific area, and extraction of a 4 cm stone of acellular material. Posteriorly, the patient was treated for three weeks with a carbapenem and physical rehabilitation was promptly initiated with full recovery of his previous status. Gallstone ileus is a very challenging diagnosis and surgery is the treatment of choice. In elderly patients, it is important to promote prompt physical rehabilitation to prevent prolonged bed rest.

Rare case of symmetrical peripheral gangrene due to septic shock, disseminated intravascular coagulation and inotropic use.

INTRODUCTION: Symmetrical peripheral gangrene (SPG) is a rare syndrome defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease. PRESENTATION OF CASE: A 45yo woman, admitted in intensive care unit due to urinary septic shock, in need of high doses of amines, developed cold extremities with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, liver shock, thrombocytopenia, prolonged coagulation times, increased D-Dimers and isolation of Acinetobacter baumanni in urine culture. An intravenous vasodilator was initiated with clinical benefits. After improvement and delimitation of the lesions, the patient underwent the amputation of the distal phalanges of the 2nd, 3rd and 4th fingers of the right hand and the toes of both feet. DISCUSSION/CONCLUSION: Even though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasodilators are used, in order to avoid major amputation.

Posterior retroperitoneoscopic adrenalectomy-Case series.

INTRODUCTION: Posterior retroperitoneoscopic adrenalectomy has advantages over transperitoneal technique. However many surgeons prefer the transperitoneal technique because they get a familiar and wider working space. MATERIAL AND METHODS: A retrospective analysis of the first 10 patients submitted to posterior retroperitoneoscopic adrenalectomy was conducted. Data collected included: diagnosis, size, operation time, blood loss, conversion rate, morbidity and mortality, in-hospital length of stay. Compare our outcomes with worldwide bigger series, and take conclusions on the feasibility of the technique was the objective. RESULTS: We included 2 pheochromocytomas, 1 giant cystic pheochromocytoma, 4 Conn's, 2 Cushing's, 1 non-functioning tumor with 4 cm. Mean operation time was 46,7 min for lesions ranging from 1,8 to 14 cm. Blood loss was negligible. One patient (10%) was converted to laparotomy because of a past clinical history of dorsal and lumbar trauma. No morbidity and no mortality. Mean hospital length of stay was 2,2 days. DISCUSSION: Mean operation time found in bigger series published in worldwide literature is 40-105,6 min. Complication rate reported ranges from 0 to 14,4%. No mortality has been ever reported. Blood loss reported in other series is 10-50 ml. The data found in our study matches other studies data. Since the same surgeon who had never performed the technique before operated all patients, makes us believe the technique is safe and feasible. CONCLUSION: Posterior retroperitoneoscopic adrenalectomy has a small learning curve. It is technically safe and feasible. More patients will be collected to validate these results.

TGF-ß1 in Vascular Wall Pathology: Unraveling Chronic Venous Insufficiency Pathophysiology.

Chronic venous insufficiency and varicose veins occur commonly in affluent countries and are a socioeconomic burden. However, there remains a relative lack of knowledge about venous pathophysiology. Various theories have been suggested, yet the molecular sequence of events is poorly understood. Transforming growth factor-beta one (TGF-ß1) is a highly complex polypeptide with multifunctional properties that has an active role during embryonic development, in adult organ physiology and in the pathophysiology of major diseases, including cancer and various autoimmune, fibrotic and cardiovascular diseases. Therefore, an emphasis on understanding its signaling pathways (and possible disruptions) will be an essential requirement for a better comprehension and management of specific diseases. This review aims at shedding more light on venous pathophysiology by describing the TGF-ß1 structure, function, activation and signaling, and providing an overview of how this growth factor and disturbances in its signaling pathway may contribute to specific pathological processes concerning the vessel wall which, in turn, may have a role in chronic venous insufficiency.

Variability of MMP/TIMP and TGF-ß1 Receptors throughout the Clinical Progression of Chronic Venous Disease.

Chronic venous disease (CVeD) is a prevalent condition with a significant socioeconomic burden, yet the pathophysiology is only just beginning to be understood. Previous studies concerning the dysregulation of matrix metalloproteinases (MMPs) and their inhibitors (tissue inhibitors of metalloproteinases (TIMPs)) within the varicose vein wall are inconsistent and disregard clinical progression. Moreover, it is highly plausible that MMP and TIMP expression/activity is affected by transforming growth factor (TGF)-ß1 and its signaling receptors (TGFßRs) expression/activity in the vein wall. A case-control study was undertaken to analyze genetic and immunohistochemical differences between healthy (n = 13) and CVeD (early stages: n = 19; advanced stages: n = 12) great saphenous vein samples. Samples were grouped based on anatomic harvest site and subjected to quantitative polymerase chain reaction for MMP1, MMP2, MMP8, MMP9, MMP12, MMP13, TIMP1, TIMP2, TIMP3, TIMP4, TGFßR1, TGFßR2, and TGFßR3 gene expression analysis, and then to immunohistochemistry for immunolocalization of MMP2, TIMP2, and TGFßR2. Decreased gene expression of MMP12, TIMP2, TIMP3, TIMP4, and TGFßR2 was found in varicose veins when compared to controls. Regarding CVeD clinical progression, two facts arose: results across anatomical regions were uneven; decreased gene expression of MMP9 and TGFßR3 and increased gene expression of MMP2 and TIMP3 were found in advanced clinical stages. Most immunohistochemistry results for tunica intima were coherent with qPCR results. In conclusion, decreased expression of TGFßRs might suggest a reduction in TGF-ß1 participation in the MMP/TIMP imbalance throughout CVeD progression. Further studies about molecular events in the varicose vein wall are required and should take into consideration the venous anatomical region and CVeD clinical progression.