Late massive hemothorax by transection of the pericardiophrenic artery by costal fracture. Report of a case.

Hasta un 8% de los pacientes sometidos a toracotomía urgente tras un traumatismo cerrado presentan una lesión costal que había pasado inadvertida inicialmente. Tal es el caso clínico que presentamos, en el que la lesión costal pasó inadvertida en la evaluación inicial y 72 horas después, al referir el paciente dolor en el hemitórax izquierdo, se solicitó tomografía simple y contrastada de tórax, y se evidenció hemotórax masivo y fracturas de arcos costales 5.º y 6.º izquierdos en su porción lateral, además de fractura de los arcos costales 7.º y 8.º en su porción paraesternal. Se realizó toracotomía exploradora con reparación diafragmática y ligadura de arteria.Up to 8% of patients undergoing urgent thoracotomy after closed trauma present a rib lesion that had initially gone unnoticed, such is the clinical case that we present, passing the inadvertent costal lesion in the initial evaluation, 72 hours later refers to pain level of left hemithorax, simple and contrasted chest tomography was requested, showing massive hemothorax and fractures of left costal arches in its lateral portion of 5th and 6th, in addition to fracture of the 7th and 8th costal arch in its parasternal portion, exploratory thoracotomy was performed with diaphragmatic repair and artery ligation.

Usefulness of serum amylase and lipase as predictors of the severity of post-endoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND: Post-ERCP pancreatitis (PEP) is the most common complication of Post-endoscopic retrograde cholangiopancreatography. OBJECTIVE: to demonstrate whether serum amylase and lipase values correlate with the presence and severity of PEP. METHOD: We conducted a retrospective, observational and analytical study of patients who underwent ERCP, those who developed pancreatitis were classified by severity according to the 2012 revised Atlanta criteria and their serum enzyme levels were analyzed. We used ROC (Receiver Operating Characteristics) curves to know the best enzyme cutoff points and analyzed their diagnostic yields. Chi-square, t-distribution and Mann-Whitney U test were used in the variable analysis and it was considered statistically significant when p < 0.05. RESULTS: A total 621 patients, 54 presented pancreatitis. For moderately severe and severe forms: lipase level of 1500 U/L had an area under the curve (AUC) = 0.827, 95% CI (0.67-0.98), sensitivity = 72.7%, specificity = 86%, negative predictive value = 92.5%, p < 0.05. Amylase level of 920 U/L presented AUC = 0.65, 95% CI (0.43-0.86), sensitivity = 63%, specificity = 67%, p > 0.05. CONCLUSIONS: Serum lipase shows correlation with the presence and severity of PEP. Amylase shows no significant correlation with PEP.

ANTECEDENTES: La pancreatitis poscolangiopancreatografía retrógrada endoscópica (PPCPRE) es la complicación más frecuente de este procedimiento. OBJETIVO: Demostrar si la amilasa y la lipasa séricas se correlacionan con la presencia y la gravedad de la PPCPRE. MÉTODO: Realizamos un estudio retrospectivo, observacional y analítico de pacientes a quienes se realizó CPRE. Los que desarrollaron pancreatitis se clasificaron por gravedad de acuerdo con la revisión de Atlanta de 2012 y se analizaron sus concentraciones séricas de enzimas. Empleamos curvas ROC (Receiver Operating Characteristics) para conocer los mejores puntos de corte enzimáticos y analizamos sus rendimientos diagnósticos. Usamos las pruebas de ji al cuadrado, t de Student y U de Mann Whitney para el análisis de las variables, y se consideró estadísticamente significativo un valor de p < 0.05. RESULTADOS: De un total de 621 pacientes, 54 presentaron pancreatitis. Para pancreatitis moderadamente grave y grave, unas cifras de lipasa de 1500 U/l presentaron un área bajo la curva (AUC) = 0.827 (intervalo de confianza del 95% [IC 95%]: 0.67-0.98), con una sensibilidad del 72.7%, una especificidad del 86% y un valor predictivo negativo del 92.5% (p < 0.05); y unas cifras de amilasa de 920 U/l presentaron un AUC = 0.65 (IC 95%: 0.43-0.86), con una sensibilidad del 63% y una especificidad del 67% (p > 0.05). CONCLUSIONES: La lipasa muestra correlación con la presencia y la gravedad de la PPCPRE. La amilasa muestra correlación no significativa con la PPCPRE.

Fatal outcome of an anaplastic thyroid tumour.

Anaplastic thyroid cancer is a rare form of thyroid cancer, known for its very poor prognosis, even with the appropriate management. It is very aggressive, with a tendency to invade locally and lymph node metastasis is often present at the time of diagnosis. We present an elderly patient, who presented with rapid enlarging neck mass, which, within weeks, led to his death. His family gave their consent to perform an autopsy, and here we describe and illustrate the profound aggressiveness of this tumour.

Gallstone ileus presenting as obstructive gangrenous appendicitis.

We present the very unusual case of a 38-year-old woman with acute appendicitis and intestinal obstruction. During surgery, a 2.5 cm gallstone impacted at the base of the cecal appendix was found as the cause of a gangrenous appendicitis and obstruction; a choledochal-duodenal fistula was found during the same surgery with no gallstones remaining in the gallbladder or elsewhere. The case was managed by appendectomy with retrieval of the gallstones and no other procedure was performed for the gallbladder or the fistula, since no other gallstone was found on examination. Previously, she was found to have a round, radio-opaque image on the right iliac fossa on imaging, initially identified as an appendicolith, but after pathological examination it turned out to contain cholesterol and calcium bilirubinate. Gallstone ileus as the cause of an obstructive gangrenous appendicitis is a very unusual disease presentation that should be kept in mind when finding an unusual appendicolith presentation in or out the appendix.

Gallstone ileus presenting as obstructive gangrenous appendicitis

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[Obesity and complicated diverticular disease of the colon]. / Obesidad y enfermedad diverticular del colon complicada.

BACKGROUND: The incidence of diverticular disease of the colon has been rising in recent years, and the associated factors are: low ingestion of fibre, age, lack of physical activity, and obesity. METHODS: A retrospective, descriptive, observational study was conducted on patients with the diagnosis of complicated diverticular disease requiring surgical or interventional treatment, for a period of 12 years. RESULTS: A total of 114 patients (72 males, and 42 females), age range 28-91 years. More than three-quarters (88 patients; 77.19%) had a body mass index (BMI) between 25 and 40 kg/m(2), and 26 patients (22.8%) had a BMI between 20 and 25 kg/m(2). Among the patients with BMI less than 25 kg/m(2), 12 patients had Hinchey 1 (46%), 8 Hinchey 2 (30.7%), 4 Hinchey 3 (15.4%), and two Hinchey 4 (7.7%). Of the patients with BMI greater than 25 kg/m(2), 19 patients had Hinchey 1 (21.6%), 24 Hinchey 2 (27.3%), 27 Hinchey 3 (30.7%), and 18 Hinchey 4 (20.45%). A statistically significant difference (P<0.001) was found between groups using Mann-Whitney U test. The BMI greater than 25 kg/m(2) as risk factor for complicated diverticular disease showed Odds Ratio of 3.4884 (95% confidence interval 1.27-9.55) with Z value of 2.44 (P=0.014). CONCLUSIONS: In this study, obesity was associated with an increased incidence and severity of complicated diverticular disease.

Resizing buffer rods for ultrasound testing of food products with acoustic noise considerations.

Buffer rods can be used to perform non-destructive and on-line analysis of food and beverage products. These rods, usually solid cylinders, can be long and heavy for certain applications. In this paper, a resizing analytic procedure is described. Buffer rods designed following this new procedure can be several times shorter than the conventionally designed ones, optimising thus their weight and cost. The signal to noise ratio (SNR) of the resized buffers is also studied in order to determine their practical usability. To this effect, simulations and experiments are conducted using metal and plastic buffer rod materials appropriate for food and beverage testing such as aluminium and polyethylene.

Complicated diverticular colon disease in patients younger than 35 years: report of two cases and literature review.

BACKGROUND: Complicated colonic diverticular disease in young patients is a rare entity, with an incidence <10% from all patients in the largest series. CLINICAL CASES: We present two cases of complicated diverticular disease in patients <35 years old treated at the Hospital Juárez of México City. Both patients had acute abdominal pain with several days of evolution. In both patients, emergency surgery was performed and postoperative evolution was favorable. CONCLUSIONS: Some authors have concluded that diverticulitis in younger patients demonstrates a more aggressive course than in older patients and with an increased risk of complications. Therefore, most physicians recommended elective resection after a single attack in such patients. Conversely, some recent reports highlighted that the clinical course and complications are similar in both age groups.

Enfermedad diverticular del colón complicada en pacientes menores de 35 años: presentación de dos casos y revisión de la literatura / Complicated diverticular colon disease in patients younger than 35 years: report of two cases and literature review

Introducción: La enfermedad diverticular complicada del colon es rara en pacientes jóvenes, estimándose una incidencia menor a 10 % en las grandes series. Casos clínicos: Se describen dos pacientes menores de 35 años de edad con complicaciones de enfermedad diverticular, atendidos en el Hospital Juárez de México; ambos presentaron cuadro de abdomen agudo de pocos días de evolución y requirieron cirugía de urgencia, con buena evolución posoperatoria. Conclusiones: Algunos autores consideran que la diverticulitis en los pacientes jóvenes puede tener un comportamiento con más complicaciones que en lo mayores. Incluso se recomienda la resección electiva del segmento afectado después del primer episodio de diverticulitis. No obstante, informes recientes han señalado que el comportamiento de las complicaciones de la enfermedad diverticular puede ser el mismo en los pacientes jóvenes y en los de mayor edad.

BACKGROUND: Complicated colonic diverticular disease in young patients is a rare entity, with an incidence <10% from all patients in the largest series. CLINICAL CASES: We present two cases of complicated diverticular disease in patients <35 years old treated at the Hospital Juárez of México City. Both patients had acute abdominal pain with several days of evolution. In both patients, emergency surgery was performed and postoperative evolution was favorable. CONCLUSIONS: Some authors have concluded that diverticulitis in younger patients demonstrates a more aggressive course than in older patients and with an increased risk of complications. Therefore, most physicians recommended elective resection after a single attack in such patients. Conversely, some recent reports highlighted that the clinical course and complications are similar in both age groups.

[Postobstetric rectovaginal fistula: surgical treatment using endorectal advancement flap]. / Fístula rectovaginal posobstétrica: tratamiento quirúrgico mediante avance de colgajo endorrectal.

BACKGROUND: Rectovaginal fistulas account for <5% of all rectal fistulas. Obstetrical injuries are the most common cause of these types of fistulas. There have been a multitude of surgical approaches developed for operative repair. METHODS: Between January 1992 and December 2006, 16 patients with postobstetric rectovaginal fistula were treated at the Hospital Juárez of México. Age, type of obstetric trauma, time elapsed between delivery and beginning of symptoms, location, and size of the fistulas, rate of success and recurrence with the use of endorectal flap, and need for complementary sphincteroplasty were all evaluated. RESULTS: Median age of the patients was 25.6 years. All women reported that their symptoms began after a vaginal delivery that included an episiotomy or 4th degree laceration. All fistulas were low and small (<2.5 cm in diameter). Patients received bowel preparation and underwent rectovaginal repair using endorectal advancement flap. In two cases, additional overlap repair of the anal sphincter was performed. Result of repair was good to excellent in 15 patients (93.7%). There were no operative mortalities, and no covering stomas were used. CONCLUSIONS: Endorectal flap repair provides successful postobstetric rectovaginal fistula closure. Concomitant sphincteroplasty may be necessary in some cases.

Fístula rectovaginal posobstétrica: tratamiento quirúrgico mediante avance de colgajo endorrectal / Postobstetric rectovaginal fistula: surgical treatment using endorectal advancement flap

Introducción: Las fístulas rectovaginales ocurren con una frecuencia menor a 5 % respecto a otros tipos de fístulas de la región anorrectal; el trauma obstétrico es la causa más común de este tipo de fístulas. Existen diversos procedimientos quirúrgicos para la reparación de las mismas. Material y métodos: Se realizó un estudio de 16 pacientes con diagnóstico de fístula rectovaginal posobtétrica, atendidas en el Hospital Juárez de México entre enero de 1992 y diciembre de 2006. Se analizó edad de las pacientes, tipo de trauma obstétrico, tiempo de inicio de la sintomatología después del parto, localización y tamaño de la fístula, índice de éxito y recidivas mediante el tratamiento con avance de colgajo endorrectal, y necesidad de esfinteroplastia complementaria. Resultados: La edad promedio fue de 25.6 años. En todas las pacientes, la sintomatología inició después de un parto vaginal durante el cual se realizó episiotomía o hubo desgarro perineal. Todas las fístulas fueron menores de 2.5 cm de diámetro y de localización baja. Con el colon preparado, en todas las pacientes se reparó la fístula rectovaginal mediante avance de colgajo endorrectal. En dos pacientes se llevó acabo, además, esfinteroplastia del esfínter anal. Los resultados fueron satisfactorios en 15 pacientes (93.7 %); no hubo mortalidad operatoria y no fueron utilizados estomas de protección. Conclusiones: El colgajo endorrectal es un procedimiento seguro para la reparación de fístulas rectovaginales de origen posobstétrico, algunos casos pueden requerir esfinteroplastia del esfínter anal.

BACKGROUND: Rectovaginal fistulas account for <5% of all rectal fistulas. Obstetrical injuries are the most common cause of these types of fistulas. There have been a multitude of surgical approaches developed for operative repair. METHODS: Between January 1992 and December 2006, 16 patients with postobstetric rectovaginal fistula were treated at the Hospital Juárez of México. Age, type of obstetric trauma, time elapsed between delivery and beginning of symptoms, location, and size of the fistulas, rate of success and recurrence with the use of endorectal flap, and need for complementary sphincteroplasty were all evaluated. RESULTS: Median age of the patients was 25.6 years. All women reported that their symptoms began after a vaginal delivery that included an episiotomy or 4th degree laceration. All fistulas were low and small (<2.5 cm in diameter). Patients received bowel preparation and underwent rectovaginal repair using endorectal advancement flap. In two cases, additional overlap repair of the anal sphincter was performed. Result of repair was good to excellent in 15 patients (93.7%). There were no operative mortalities, and no covering stomas were used. CONCLUSIONS: Endorectal flap repair provides successful postobstetric rectovaginal fistula closure. Concomitant sphincteroplasty may be necessary in some cases.

[Heller's myotomy with fundoplication by endoscopic surgery]. / Miotomía de Heller con funduplicatura por via laparoscópica (tratamiento endoquirúrgico de la acalasia).

BACKGROUND: We undertook this study to present a 5-year experience in laparoscopic treatment of achalasia using Heller myotomy with an antireflux technique. METHODS: Fourteen patients with diagnosis of achalasia were included. We analyzed age, sex, symptoms, endoscopy, radiology and manometry results, pre- and postoperative treatment, fundoplication technique, surgical time and Visick Score. RESULTS: Heller myotomy with an antireflux technique was carried out in 14 patients: Dor was performed in eight patients, Toupet in four patients, and Nissen in two patients. Average surgical time was 145 min, which decreased to 130 min in those patients who underwent Dor fundoplication. Oral feeding was started 1.5 days after surgery and the average hospital stay was 2.5 days. Visick Score was as follows: grade I-six patients (42.8%, Dor four patients, Toupet one patient, Nissen one patient); grade II-four patients (28.5%, Dor three patients, Toupet one patient); grade IIIA-two patients (14.2%, Dor two patient); grade IVA-one patient (7.1%, Toupet); grade IVB-one patient (7.1%, Nissen-Rossetti). CONCLUSIONS: Heller myotomy is currently the gold standard in the treatment of achalasia and should be performed with an antireflux procedure. In our series, we have found that there are fewer complications with Dor fundoplication, the procedure is easier (implying shorter surgical time), and it offers the best results as compared with other antireflux techniques.

Pancreatogastroanastomosis modificada y preservación de píloro posterior a pancreatoduodenectomía: reporte de un caso y revisión de la literatura / Modified pancreatogastrostomy and presentation of the pylorus after pancreatoduodenectomy: a case report and review of the literature

Actualmente se han realizado modificaciones en la reconstrucción de la pancreatoduodenectomía con claras ventajas teóricas y prácticas que han aportado beneficios en la morbilidad y la mortalidad de esta cirugía mayor. Aquí se presenta un caso de pancreatoduodenectomía con preservación de píloro y reconstrucción con pancreatogastroanastomosis con buenos resultados, con el cual ejemplificamos las ventajas técnicas y fisiológicas de cada procedimiento para los pacientes que requieren una pancreatoduodenectomía. Un paciente masculino de 38 años de edad, con cuadro de ictericia y pérdida de peso de dos meses de evolución, acudió al Hospital Juárez de México, donde se le diagnostica adenocarcinoma de ámpula de Vater. Se decide realizar una pancreatoduodenectomía como procedimiento quirúrgico. Ésta se realiza con preservación de píloro y con una reconstrucción pancreatogastroanastomótica. El diagnóstico definitivo fue de un adenocarcinoma de ámpula de Vater, estadio III (T1, N1, Mx). El paciente evoluciona satisfactoriamente, siendo egresado al 14§ día. Se le da quimioterapia y radioterapia concomitante.Sugerimos con el presente artículo la reconstrucción con la pancreatogastroanastomosis y la conservación de píloro, porque con la primera hay un menor índice de fugas anastomóticas y con la segunda se disminuye la posibilidad de un síndrome posgastrectomía. Cada uno de los factores representan disminución en la morbilidad y mortalidad de los pacientes sometidos a pancreatoduodenectomía.

Resección abdominoperineal por vía laparoscópica / Laparoscopic abdominoperineal resection

Con el objetivo de conocer la relación entre la presión intraabdominal (PIA) y la mortalidad en el paciente quirúrgico grave, se realizaron mediciones seriadas de la PIA, a través de catéter vesical, en 92 pacientes seleccionados al azar de los 176 admitidos en nuestra Unidad de Cuidados Intensivos en un periodo de dos años. La puntuación media APACHE II al ingreso fue de 20 + 4.52. Los pacientes con hemoperitoneo posoperatorio, empaquetamiento abdominal, abscesos intraabdominales y edema visceral posresucitación, presentaron las mayores cifras de PIA. El coeficiente de correlacón de Pearson fue de + 0.96. Presentó complicacones intraabdominales, 89.6 por ciento de los fallecidos. Las principales causas de muerte fueron: el Síndrome de Disfunción Orgánica Múltiple (SDOM) y el choque distributivo. Se concluye que la PIA debe monitorizarse en el paciente quirúrgico grave. Esta técnica permite realizar el diagnóstico del Síndrome del Compartimiento Abdominal y de complicaciones intraabdominales que obligan a relaparotomizar al paciente.

Cirugía de tiroides; indicaciones y complicaciones: experiencia en el Hospital Juárez de México (1989-1991) / Thyroid surgery; indications and complications: experience in the Hospital Juárez de México (1989-1991)

La tiroidectomía total o parcial sigue siendo el tratamiento de elección en muchos casos de patología tiroidea; sin embargo, como cualquier intervención quirúrgica, la cirugía sobre la glándula tiroides no está exenta de presentar complicaciones, aunque no con la frecuencia de antaño, aún observamos casos de hipocalcemia, disfonía e infección o hematoma sobre la herida quirúrgica como las más frecuentes. Es la intención del presente reporte conocer la incidencia de complicaciones y las indicaciones de cirugía en los pacientes tratados en un hospital escuela como es el Hospital Juárez de México.