Himen imperforado y hematocolpos por retención urinaria y dolor abdominal: reporte de un caso clínico / Imperforate hymen and hematocolpos as a cause of urinary retention and abdominal pain: A clinical case report

Resumen ANTECEDENTES: El himen imperforado es una malformación congénita del aparato genital femenino, con incidencia de 0.1%. El desarrollo del himen ocurre con la proliferación de los senos bulbo-vaginales y estos se perforan de forma normal antes o después del nacimiento. Al llegar a la adolescencia, la mayoría de los casos suelen manifestar: amenorrea, dolor pélvico, retención urinaria, o los tres. CASO CLÍNICO: Paciente de 12 años, llevada al servicio de Urgencias debido a dolor abdominal intenso y retención urinaria. Primero se estableció el diagnóstico de quiste gigante de ovario; sin embargo, la laparotomía exploradora no evidenció alteraciones ováricas. Mediante estudios de imagen y la exploración física detallada se estableció el diagnóstico de hematocolpos e himen imperforado. Se decidió efectuar la himenoplastia, con lo que se resolvió el cuadro clínico. CONCLUSIONES: El himen imperforado puede causar retención urinaria y dolor abdominal; por tanto, la manifestación de estos síntomas debe considerarse en el diagnóstico diferencial de pacientes adolescentes.

Abstract BACKGROUND: Imperforate hymen is an uncommon congenital malformation of the genital tract, its incidence is 0.1%. Physiologically the development of the hymen occurs for the proliferation of the sinovaginal bulbs, they usually will perforate before or after born. The majority of cases will show clinical manifestations when patient reach puberty, the most common are pelvic pain, amenorrhea and urinary retention. CLINICAL CASE: This is a 12-year-old adolescent patient who went to the emergency department for severe abdominal pain and urinary retention. Initially, the patient was diagnosed with a giant ovarian cyst and a laparotomy was performed without finding ovarian pathology. However, through imaging studies and a more detailed physical examination, the diagnosis of hematocolpos and imperforate hymen was reached. The patient was subsequently subjected to hymenoplasty, which resolved the condition. CONCLUSIONS: The presence of imperforate hymen can cause urinary retention and abdominal pain. It should be suspected in adolescent patients.

Spontaneous rupture of the spleen secondary to amyloidosis.

BACKGROUND: Rupture of the spleen has been classically associated with trauma. It sometimes is a spontaneous event or may be secondary to a pathological condition of the spleen or even in a healthy spleen. Systemic amyloidosis is characterized by the extracellular deposition of amyloid proteins in one or more organs. The spleen can be affected in 41% of patients. We undertook this study to present a case of spontaneous splenic rupture secondary to amyloid infiltration of the spleen, an uncommon condition in the literature. CLINICAL CASE: We present the case of a 46-year-old male with abdominal pain, fever, abdominal distention and tachycardia. There were peritoneal signs during physical examination and leukocytosis was reported in the laboratory tests. The patient previously received analgesics and we suspected acute appendicitis modified by medications. It was decided to perform a laparotomy, finding hemoperitoneum as a consequence of spleen rupture. We performed splenectomy with a favorable patient outcome. Histopatological study reported amyloid infiltration of the spleen. CONCLUSIONS: In patients with abdominal pain and hypotension, we should suspect the possibility of a spontaneous splenic rupture, even without trauma or infection.

[Double stapler technique in colorectal surgery]. / Doble engrapado en cirugía colorrectal.

BACKGROUND: Colorectal surgery has evolved significantly during the last 35 years. The circular stapler and the double stapler techniques have favored the development of very low rectal anastomoses with reduction in anastomotic leakage. The objective of this study is to evaluate the functional results and complication rate of this surgical technique in the Department of Colorectal Surgery at the Hospital de Especialidades, Centro Medico Nacional Siglo XXI and at the Hospital Angeles del Pedregal, both located in Mexico City. METHODS: Clinical records of patients who underwent surgery from May 1995 to December 2005 using the double stapler technique and performed by the authors were reviewed. RESULTS: The study included 142 patients, 55 of whom had rectosigmoid cancer resections. Average age was 60.1 years (male predominance 52.05%). The circular stapler most frequently used was CDH 33 (Johnson & Johnson). Average distance between the anal margin and the anastomoses for extended low anastomoses was 3.21 cm (low 7.8 cm and high 13.7 cm), and the rate of anastomoses leak was 3.52%. CONCLUSIONS: Double stapler technique used to treat rectosigmoid pathology is safe, secure and assures intestinal continuity in low anterior as well as extended low anterior resections with primary anastomoses. In those patients with associated risk factors and low extended low anterior resection with primary anastomoses, we recommend performing a protective stoma (ileostomy).

Doble engrapado en cirugía colorrectal / Double stapler technique in colorectal surgery

BACKGROUND: Colorectal surgery has evolved significantly during the last 35 years. The circular stapler and the double stapler techniques have favored the development of very low rectal anastomoses with reduction in anastomotic leakage. The objective of this study is to evaluate the functional results and complication rate of this surgical technique in the Department of Colorectal Surgery at the Hospital de Especialidades, Centro Medico Nacional Siglo XXI and at the Hospital Angeles del Pedregal, both located in Mexico City. METHODS: Clinical records of patients who underwent surgery from May 1995 to December 2005 using the double stapler technique and performed by the authors were reviewed. RESULTS: The study included 142 patients, 55 of whom had rectosigmoid cancer resections. Average age was 60.1 years (male predominance 52.05%). The circular stapler most frequently used was CDH 33 (Johnson & Johnson). Average distance between the anal margin and the anastomoses for extended low anastomoses was 3.21 cm (low 7.8 cm and high 13.7 cm), and the rate of anastomoses leak was 3.52%. CONCLUSIONS: Double stapler technique used to treat rectosigmoid pathology is safe, secure and assures intestinal continuity in low anterior as well as extended low anterior resections with primary anastomoses. In those patients with associated risk factors and low extended low anterior resection with primary anastomoses, we recommend performing a protective stoma (ileostomy).

Calidad de vida después de proctocolectomía restaurativa con reservorio ileoanal en J en pacientes con colitis ulcerativa / Quality of life after restorative proctocolectomy with ileo-anal J pouch in patients with ulcerative colitis

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most common treatment in patients with ulcerative colitis. This procedure removes the entire colon, conserving the sphincteric complex and, therefore, preserving continence. The most important goal of this surgery is to improve quality of life. METHODS: We reviewed the files of patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis from January 1995 to December 2004 . We administered questionnaire SF-36 to evaluate quality of life. We used an observational, retrospective, and transversal method. RESULTS: Twenty J pouch procedures were done, of which files of 14 patients were reviewed. As far as quality of life, we were able to interview only eight patients and the average was as follows: physical function 75, physical status 50, corporal pain 51, general health 77, vitality 47.5, social function 62.50, emotional status 83 and mental health 74. DISCUSSION: Previous reports exist showing that proctocolectomy is a safe and effective procedure for patients with ulcerative colitis and where ileostomy is accompanied by one definitive, independent continent or pouch. CONCLUSIONS: The presence of stoma and fecal incontinence are factors that contribute to deterioration of quality of life after proctocolectomy; thus, both should be avoided. Of the patients who we interviewed, 87.5% consider that their health status has improved during 1 year.

[Quality of life after restorative proctocolectomy with ileo-anal J pouch in patients with ulcerative colitis]. / Calidad de vida después de proctocolectomía restaurativa con reservorio ileoanal en "J" en pacientes con colitis ulcerativa.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the most common treatment in patients with ulcerative colitis. This procedure removes the entire colon, conserving the sphincteric complex and, therefore, preserving continence. The most important goal of this surgery is to improve quality of life. METHODS: We reviewed the files of patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis from January 1995 to December 2004 . We administered questionnaire SF-36 to evaluate quality of life. We used an observational, retrospective, and transversal method. RESULTS: Twenty "J" pouch procedures were done, of which files of 14 patients were reviewed. As far as quality of life, we were able to interview only eight patients and the average was as follows: physical function 75, physical status 50, corporal pain 51, general health 77, vitality 47.5, social function 62.50, emotional status 83 and mental health 74. DISCUSSION: Previous reports exist showing that proctocolectomy is a safe and effective procedure for patients with ulcerative colitis and where ileostomy is accompanied by one definitive, independent continent or pouch. CONCLUSIONS: The presence of stoma and fecal incontinence are factors that contribute to deterioration of quality of life after proctocolectomy; thus, both should be avoided. Of the patients who we interviewed, 87.5% consider that their health status has improved during 1 year.

[Anal incontinence caused by an obstetric trauma. Experience with the technique of overlapping sphincteroplasty]. / Incontinencia anal causada por un traumatismo obstétrico. Experiencia con la técnica de esfinteroplastia por superposición.

INTRODUCTION: Anal incontinence (IA) could be of idiopathic, congenital, neurological origin, or secondary to trauma. Obstetric trauma is the most common cause of the traumatic anal incontinence. OBJECTIVE: To analyze results of a group of patients with anal incontinence secondary to obstetric trauma, with overlapping sphincteroplasty. PATIENTS AND METHODS: All patients with anal incontinence secondary to obstetric trauma without neurological damage, between January 2002 to January 2006 were studied; all of them underwent overlapping sphincteroplasty. We evaluated improvement in incontinence score according Jorge and Wexner incontinence scale, pre and postoperatively as well as morbi-mortality rates. RESULTS: 16 patients, most of them with total anal incontinence, with preoperative values between 16 to 20 points at the Jorge and Wexner scale; 14 patients (87.5%) referred improvement in their values with 4 to 0 points postoperatively, two patients did not refer significant improvement, both of them with defects in both sphincters and loss of the 50% of the entire sphincteric complex. They were sent to bio-feedback therapy. There was not mortality. Seven patients (43.7%) had skin dehiscence. CONCLUSIONS: Overlapping sphincteroplasty is an accurately technique for repair obstetric trauma injuries of the anal sphincter, with a success rate of 70 to 80%, and a low morbidity rate.

Helicoidal suture: alternative treatment for complete rectal prolapse in high-risk patients.

BACKGROUND AND AIMS: Optimal treatment for rectal prolapse is controversial. We describe a novel alternative treatment for high-risk patients with complete rectal prolapse. PATIENTS AND METHODS: Sixteen high-risk patients over 60 years old with complete rectal prolapse were examined. All patients had significant past medical history and were classified as grade III (ASA) surgical risk. The helicoidal suture technique is described. Postoperative parameters evaluated were morbidity, mortality, postoperative symptoms, recurrence and anal incontinence score. Median follow-up was 60 months. RESULTS: There were no operative complications or mortality in the series; one patient experienced recurrence. Median postoperative anal incontinence score was 6.06 (range 1-30; preoperative 23.6). CONCLUSION: This technique provides adequate functional outcomes and could be an effective therapeutic strategy against rectal prolapse in high-risk patients.

[Surgical treatment of complete rectal prolapse. Experience at a colon and rectal surgery service]. / Tratamiento quirúrgico del prolapso rectal completo. Experiencia en el Servicio de Cirugía de Colón y Recto.

BACKGROUND: Rectal prolapse is as ancient humanity. Treatment must be surgical in adult patients. There is no gold standard procedure to date; thus, this has given rise to controversy. OBJECTIVE: One objective was to analyze our results, complications, mortality, and recurrence in a Colorectal Surgery Service for surgical treatment of complete rectal prolapse. PATIENTS AND METHODS: We reviewed records of all patients treated surgically with rectal prolapse at our Service from March 1995 to March 2001. RESULTS: 31 patients; 22 were female and nine male with age range of 24 to 89 years. Evolution time was 6 months to 40 years; 11 patients had preoperative incontinence. We carried our four procedures, abdominal procedure hospital stay was 4 to 7 days; we had 18% long-term complications with no mortality or recurrence. Hospital stay in perineal procedures was 1 to 2 days with one procedure associated with death due to AV blockade, with 14% recurrence for helicoidal suture procedure, and no complications. Altemeier procedure recurred at 1 month of surgery. Continence score of Miller improve postoperatively. CONCLUSIONS: Abdominal procedures have less recurrence than perineal procedures; abdominal procedures must be considered in young patients with low risk, and perineal procedures in older patients with high risk, that are coantraindications for a major surgical procedure.

Colonic tuberculosis.

Tubercle bacillus was discovered in 1882 by Robert Koch. With the introduction of chemotherapy for tuberculosis in the 1940s the incidence of this entity decreased. The incidence of the tuberculosis of the colon began to increase at the 1980s with the rise in numbers of patients considered as high risk for this entity, such as HIV-infected individuals, patients with chronic renal disease, and immunosuppressed patients with prolonged steroid therapy. We report on two patients with history of chronic abdominal pain and weight loss with a palpable mass in the right lower quadrant. In one patient chest radiography revealed a miliary reticulonodular pattern. In both, abdominal CT scan showed retroperitoneal lymphadenopathy and colonic wall thickness. Colonoscopic examination showed ulcerative lesions and ileocecal valve disruption. Microscopic examination of intestinal content showed evidenced M. tuberculosis. Tuberculosis of the colon should be suspected in patients suffering from chronic abdominal pain and weight loss.

[Colonic primary lymphoma]. / Linfoma primario de colon.

UNLABELLED: Primary colon lymphomas (PCL) are very rare tumors of the gastrointestinal tract, and represent 0.2-0.5% of all colon primary tumors. They appear principally PCL in adult population. Almost all are non-Hodgkin's lymphomas; first however, one must discard lymph node origin. The most frequent sites of presentation are the cecum and rectum. Treatment of choice is surgical, plus adjuvant chemotherapy. Radiotherapy is reserved for specific cases. OBJECTIVE: To inform on two cases of PCL. METHOD: Review two of cases of cecum lymphomas and their treatment. RESULTS: We inform the cases of two patients with the diagnosis of cecum lymphoma. The main patient complaints were abdominal pain, palpable mass, and hemorrhage. Both patients were treated with right extended hemicolectomy and ileum-transverse anastomosis. The outcome was unremarkable. Both patients received chemotherapy and remain free of disease at 1.5 and 5 years of follow-up. CONCLUSIONS: Primary colon lymphomas are very uncommon gastrointestinal tumors, with cecum localization as one of the most frequent sites of presentation in the colon. Treatment of choice must be surgical, with chemotherapy as an adjuvant therapy to improve survival.

[Ischemic colitis in patients submitted to aortic replacement surgery. Risk factors]. / Colitis isquémica en pacientes sometidos a cirugía de reemplazo aórtico. Factores de riesgo.

UNLABELLED: Ischemic colitis (IC) is an important clinical problem, and may present after aortic surgical procedures. The aim of this work was to establish risk factors for IC presentation in aortic surgical replacement patients. MATERIAL AND METHODS: A retrospective study of patients with aortic surgical replacement in a 3-year period was carried out. Patients were divided into two groups: patients without IC and patients with IC, the later group subdivided into patients with gangrenous ischemic colitis and without gangrenous ischemic colitis. Multiple logistic regressions was used to obtain the variables for possible risk factor for IC. RESULTS: We included 101 patients in the study; ischemic colitis was present in 16.8% of all cases, with 47.1% of gangrenous type. Metabolic acidosis was the most frequent alteration. Diagnosis was made by endoscopy in 94.1%. Mortality in IC group was 18.2% with an increase in the gangrenous group to 62.5%. Identified risk factors were disrupted aneurysm, previous colonic surgery, emergency surgery, and hemodynamic instability. CONCLUSIONS: Ischemic colitis is most frequent in emergency surgery for disrupted aneurysm in the hemodynamically unstable patient with retroperitoneal hematoma. We must entertain a high suspicion index for IC in all patients with aortic surgical procedures for early detection and adequate treatment.

[Surgical treatment of unspecific chronic ulcerative colitis. A 5-year experience]. / Tratamiento quirúrgico de la colitis ulcerativa crónica inespecífica. Experiencia de cinco años.

BACKGROUND: Treatment of ulcerative colitis depends on clinical stage of disease and have precise surgical indications. The aim of this work was to review surgical indications and present data related to our experience. MATERIAL AND METHODS: Retrospective, descriptive, and transversal study. We reviewed records of all patients who underwent a surgical procedure for ulcerative colitis at our service from March 1996 to March 2001. RESULTS: Twenty two patients, 13 males and nine females, ages range 21 to 72 years. Main indication for surgery was no response to medical treatment (50%). Surgical procedures was subtotal colectomy with ileostomy in one patient, intersphincteric proctocolectomy with ileostomy in four intersphincteric proctectomy with ileostomy in three ileorectalanastomosis in three proctocolectomy with ileoanal "J" pouch in six and proctectomy with ileoanal J pouch in five. We had the following complications: oral candidiasis; phlebitis; eventration; pouchitis, and anal fissure in one patient, respectively, pouch-skin fistula in two patients (9%), and retrograde ejaculation in one of these. Follow-up was for 5 years. CONCLUSIONS: Surgical indications for ulcerative colitis are precise. We recommend early surgical evaluation. Ileoanal pouch is now considered the gold standard for surgical procedure because it eliminates disease, neoplasm development, and permanent extra-colonic manifestations, and restores continence.

[Perianal leukemic infiltration. Case report]. / Infiltración leucémica perianal. Informe de un caso.

BACKGROUND: Leukemic infiltration of perianal skin (leukemia cutis) is quite uncommon, and may consist of no diffuse infiltration, erythema, ulceration, fistula, and abscess. Diagnosis may be established by biopsy and adequate hematologic studies. Treatment must be conservative in patients with poorly controlled disease (sitz baths, antibiotics, radiotherapy), and surgical in patients with risk of fulminant sepsis and death. OBJECTIVE: To report a case of leukemic perianal infiltration with atypical ulcerated lesion. CASE REPORT: Female patient, 21 years of age with diagnosis of AML M7, began with perianal pain posterior to evacuation associated with bleeding; at perianal examination we found anterior atypical ulcerated lesion. We carried out a biopsy under suspicion of leukemic infiltration corroborated by histopathology. The patient received conservative treatment. CONCLUSIONS: We must suspect leukemic infiltration in patients with anal symptoms and effect close surveillance. Prognosis depends on control of hematologic disease.

Plicatura intestinal transmesentérica para la oclusión intestinal secundaria a adherencias diseminadas: Experiencia de 12 años / Transmesenteric intestinal plication for intestinal occlusion secondary to disseminated adherences: A 12-years experience

Objetivo: informar la experiencia de una técnico de plicatura intestinal en pacientes con oclusión intestinal secundaria a adherencias diseminadas con seguimientos hasta de 12 años. Antecedentes: se han descrito varias técnicas de plicatura intestinal para los pacientes con oclusión intestinal secundaria adherencias diseminadas. En 1977 el Dr. Blanco informó una técnica de plicatura intestinal transmesentérica, la cual es la que se realiza en nuestra institución. Método: se revisaron de forma retrospectiva los expedientes de 32 pacientes a quienes se les realizó este procedimiento en un periodo de 11 años. Se analizaron los resultados postoperatorios de esta técnica con base en recurrencia y mortalidad. Resultados: fueron en total 32 pacientes, 56 por ciento mujeres y 44 por ciento hombres, con edad promedio de 50 años. Todos los pacientes tenían antecedentes quirúrgicos intraabdominales. El 72 por ciento tenían antecedentes de oclusión intestinal. La evolución postoperatoria fue buena. La tasa de éxito fue superior al 90 por ciento. El seguimiento fue en promedio de 3.5 años (mediana 3 [margen 1-12] años). No hubo diferencias en cuanto recurrencia y mortalidad comparado con las técnicas de plicatura intestinal de Noble de Childs-Phillips. Conclusiones: la técnica de plicatura intestinal utilizada es útil en el manejo quirúrgico de los pacientes con oclusión intestinal secundaria a adherencias.