Métodos radiológico-quirúrgicos para la identificación de anomalías celiaco-mesentéricas de la arteria hepática ante una duodenopancreatectomía / Radiological-surgical methods to identify celiac-mesenteric anomalies of the hepatic artery before duodenopancreatectomy

Introducción: El sistema hepático arterial presenta variaciones anatómicas en hasta un 45%. La identificación pre o intraoperatoria de estas anomalías anatómicas evitará morbilidad adicional a la realización de una duodenopancreatectomía. Rutinariamente son identificadas en el preoperatorio mediante tomografía computarizada (TC). En determinadas ocasiones no son informadas y solo se descubren durante la intervención quirúrgica. El acceso inicial retroperitoneal de la arteria mesentérica superior (AMS) evitará una intervención poco útil si existe invasión de arteria mesentérica superior, e identificará las variantes anatómicas con origen en arteria mesentérica superior. Estas anomalías adquieren importancia dado que su lesión inadvertida ocasionaría severo compromiso vascular y/o hemorragias perioperatorias. Objetivos• Analizar anomalías celiaco-mesentéricas de la arteria hepática ante una duodenopancreatectomía, mediante información de tomografía computarizada multicorte (TCMD), en régimen no protocolizado, •protocolizado y con reconstrucción multidimensional, proyección de intensidad máxima (MIP), tras acceso quirúrgico inicial a AMS. Enfermos y método Estudio restrospectivo de variables clínicas, anatomopatológicas y quirúrgicas de enfermos con (..) (AU)

Introduction: Up to 45% anatomical variations are found in hepatic arterial system. Identifying these anatomical anomalies before or during surgery would prevent additional morbidity in performing a duodenopancreatectomy. They are routinely (..) (AU)

Serum VEGF and VEGF-C values before surgery and after postoperative treatment in gastric cancer.

INTRODUCTION: Angiogenesis and lymphangiogenesis are essential processes for the formation of blood and lymphatic vessels that allow tumour growth and spread. The binding of VEGF and VEGF-C factors with their receptors (VEGFR2, VEGFR3) in endothelial cells triggers signals that regulate these processes. We compared preoperative serum VEGF and VEGF-C levels with samples obtained after completion of surgery and adjuvant treatment in patients with gastric cancer. In addition, we determined the prognostic value and relationship to survival of serum VEGF and VEGF-C levels. METHODS: We used a prospective cohort study of 59 gastric cancer patients who underwent surgery. Serum VEGF and VEGF-C were measured by enzyme-linked immunosorbent assay (ELISA) the day before surgery and 6 months later, after completion of adjuvant treatment. RESULTS: Serum VEGF values decreased after treatment in patients with resectable tumours (mean ± SD) (405.42 ± 298.38 vs. 306.38 ± 212.47 pg/ml; p < 0.01), poorly differentiated and undifferentiated tumours (G3, G4) (438 ± 339.71 vs. 322.47 ± 210.71 pg/ml; p = 0.01), locally advanced gastric tumours (T4 stage) (424.27 ± 323.08 vs. 333.62 ± 221.72 pg/ml; p = 0.03) and tumours with a greater number of involved regional lymph nodes (N3) (442.38 ± 311.52 vs. 337.4 ± 203.64 pg/ml; p = 0.04). Serum preoperative VEGF values over 761 pg/ml were associated with shorter patient survival. The mean overall survival time for patients with serum VEGF levels higher than 761 pg/ml was 7 ± 2.99 months (95 % CI 1.14-12.86) while for patients with serum VEGF levels of less than 761 pg/ml was 21.18 ± 2.88 (95 % CI 15.54-26.83) The mean disease-specific survival time for patients with serum VEGF levels higher than 761 pg/ml was 6.25 ± 2.53 months (95 % CI 1.29-11.21) while for patients with serum VEGF levels of less than 761 pg/ml was 27.57 ± 3.45 (95 % CI 20.80-34.35). Multivariate analysis identified preoperative serum VEGF levels as an independent prognostic factor (HR = 0.144; p = 0.03). CONCLUSIONS: Serum VEGF levels decreased after the completion of treatment in patients with resected tumours, suggesting VEGF tracking may be useful in monitoring progression. Preoperative measurement of serum VEGF may help us identify patients with a poor prognosis.

[Radiological-surgical methods to identify celiac-mesenteric anomalies of the hepatic artery before duodenopancreatectomy]. / Métodos radiológico-quirúrgicos para la identificación de anomalías celiaco-mesentéricas de la arteria hepática ante una duodenopancreatectomía.

INTRODUCTION: Up to 45% anatomical variations are found in hepatic arterial system. Identifying these anatomical anomalies before or during surgery would prevent additional morbidity in performing a duodenopancreatectomy. They are routinely identified before surgery using CT imaging, but on certain occasions they are not reported and are only discovered during the surgical operation. The initial retroperitoneal access by the superior mesenteric artery (SMA) will avoid a fairly useless intervention if there is superior mesenteric artery invasion, and will identify the anatomical variations originating in the superior mesenteric artery. These anomalies acquire importance in that their unnoticed injury could lead to severe vascular compromise and/or perioperative bleeding. OBJECTIVES: To analyse celiac-mesenteric anomalies of the hepatic artery before duodenopancreatectomy using the information from multidetector computed tomography (MDCT) using a non-standardised method, a standardised method with multidimensional reconstruction, and maximum intensity projection (MIP), after initial surgical access to the SMA. PATIENTS AND METHODS: A retrospective study of the clinical, histopathological and surgical variables was conducted on patients with an indication for duodenopancreatectomy in our Department from 2008 until April 2010. A study was performed on the reports made after image acquisition by MDCT. A blind, three-dimensional, MIP reconstruction was performed on all the patients to identify arterial anomalies. A description is given of hepatic artery anomalies after initial access to the SMA. RESULTS: A total of 61 patients were included in the study. The mean age was 65 ± 11 years, with 33 (54%) males and 28 (46%) females. Vascular anomalies, right hepatic artery (RHA) (SMA) substitute (subst), 5 (8%); RHA (SMA) accessory (acc), 4 (7%); left hepatic artery (LHA) (left gastric artery) (LGA) acc 3 (5%); common hepatic artery (CHA) (SMA) subst 3 (5%); RHA (SMA) acc+LHA (LGA) acc2 (3%); CHA (aorta) subst, 1 (2%); RHA+RGA+2 LHA (celiac trunk), 1 (2%); and CHA (SMA)+LHA (LGA) acc. CONCLUSION: On being able to identify arterial anomalies with a mixture of preoperative radiological and methodological criteria, with three-dimensional reconstruction, MIP, and initially performing a dissection of the superior mesenteric artery could avoid duodenopancreatectomies that may not benefit the patient and compromise bleeding.

Hemorragia digestiva baja e intususcepción subsecuente a tumor del estroma gastrointestinal / Gastrointestinal bleeding and intussusception due to gastrointestinal stromal tumor (GIST)

Introducción: Los tumores del intestino delgado representan 25 % de las neoplasias gastrointestinales, de ellos 0.2 y 1 % corresponde a tumores del estroma gastrointestinal. Su presentación clínica más frecuente es la hemorragia digestiva, siendo los tumores del estroma gastrointestinal responsables en 1 % de los casos. Este tipo de neoplasias también puede ser el origen de intususcepción, proceso patológico infrecuente en la edad adulta por representar únicamente 5 % de todas las obstrucciones intestinales. Caso clínico: Mujer que acudió al servicio de urgencias por dolor abdominal y hemorragia digestiva baja. Las pruebas complementarias no resultaron concluyentes. Tras laparotomía exploradora se diagnosticó intususcepción y hemorragia digestiva baja subsecuente a tumor del estroma gastrointestinal. Conclusiones: La cirugía debe ser el último recurso diagnóstico y terapéutico, pero es necesaria en ocasiones debido a la dificultad para determinar la causa etiológica de la hemorragia y la obstrucción intestinal.

BACKGROUND: Small bowel tumors comprise 25% of gastrointestinal (GI) neoplasms, of which only between 0.2 and 1% correspond to gastrointestinal stromal tumors (GIST). GI bleeding is the most common presentation of GIST, being responsible in 1% of the cases. This type of neoplasm can also be the origin of an intussusception, which is an infrequent process during adult age, representing only 5% of all intestinal obstructions. CLINICAL CASE: We report a case of a patient who arrived at the emergency department due to abdominal pain and lower GI bleeding. The diagnostic process was not conclusive. After an exploratory laparotomy, the diagnosis was GI bleeding and intussusception due to GIST. CONCLUSIONS: Surgery must be the last diagnostic and therapeutic resource, but it is sometimes necessary to localize bleeding and intestinal obstruction site.

Gastrointestinal bleeding and intussusception due to gastrointestinal stromal tumor (GIST).

BACKGROUND: Small bowel tumors comprise 25% of gastrointestinal (GI) neoplasms, of which only between 0.2 and 1% correspond to gastrointestinal stromal tumors (GIST). GI bleeding is the most common presentation of GIST, being responsible in 1% of the cases. This type of neoplasm can also be the origin of an intussusception, which is an infrequent process during adult age, representing only 5% of all intestinal obstructions. CLINICAL CASE: We report a case of a patient who arrived at the emergency department due to abdominal pain and lower GI bleeding. The diagnostic process was not conclusive. After an exploratory laparotomy, the diagnosis was GI bleeding and intussusception due to GIST. CONCLUSIONS: Surgery must be the last diagnostic and therapeutic resource, but it is sometimes necessary to localize bleeding and intestinal obstruction site.

[Management of spontaneous hepatic hemorrhage due to focal nodular hyperplasia]. / Manejo terapéutico de la hemorragia espontánea hepática debido a una hiperplasia nodular focal.

Focal nodular hyperplasia is a benign liver tumor that usually follows an asymptomatic course. Hemorrhage of hepatic focal nodular hyperplasia is exceptional and occurs in tumors such as hepatocellular carcinoma and hepatic adenoma. We report the case of a woman with spontaneous rupture and hemorrhage of focal nodular hyperplasia. Hemodynamic stabilization was achieved by selective hepatic arterial embolization. Elective hepatic resection was subsequently performed. This clinical course is extremely rare. We describe the therapeutic management of these complications using hepatic transarterial embolization, which could avoid potentially harmful aggressive treatments.

Manejo terapéutico de la hemorragia espontánea hepática debido a una hiperplasia nodular focal / Management of spontaneous hepatic hemorrhage due to focal nodular hyperplasia

La hiperplasia nodular focal constituye una lesión hepática benigna, cuya evolución habitualmente es asintomática. Su presentación como hemorragia hepática espontánea es excepcional y habitualmente aparece en lesiones hepáticas, como el carcinoma y el adenoma hepatocelular. Presentamos el caso de una mujer con rotura espontánea intralesional de una hiperplasia nodular focal, con hemorragia hepática, tratada tras una estabilización hemodinámica mediante embolización selectiva arterial, para posteriormente realizar la resección hepática, debido a la excepcionalidad en el inicio clínico de la hiperplasia nodular focal, y la intención de actualizar el manejo terapéutico de estas lesiones con la embolización transarterial hepática

Focal nodular hyperplasia is a benign liver tumor that usually follows an asymptomatic course. Hemorrhage of hepatic focal nodular hyperplasia is exceptional and occurs in tumors such as hepatocellular carcinoma and hepatic adenoma. We report the case of a woman with spontaneous rupture and hemorrhage of focal nodular hyperplasia. Hemodynamic stabilization was achieved by selective hepatic arterial embolization. Elective hepatic resection was subsequently performed. This clinical course is extremely rare. We describe the therapeutic management of these complications using hepatic transarterial embolization, which could avoid potentially harmful aggressive treatments

Neumoperitoneo, neumomediastino y enfisema cervical subcutáneo tras colonoscopia / Pneumoperitoneum, pneumomediastinum and subcutaneous cervical emphysema after colonoscopy

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