Stepwise transversus abdominis muscle release for the treatment of complex bilateral subcostal incisional hernias.

BACKGROUND: Management of subcostal incisional hernias is particularly complicated due to their proximity to the costochondral limits in addition to the lack of aponeurosis on the lateral side of the abdomen. We present our results of posterior component separation through the same previous incision as a safe and reproducible technique for these complex cases. METHODS: We present a multicenter and prospective cohort of patients diagnosed with bilateral subcostal incisional hernias on either clinical examination or imaging based on computed tomography from 2014 to 2020. The aim of this investigation was to assess the outcomes of abdominal wall reconstruction for subcostal incisional hernias through a new approach. The outcomes reported were short- and long-term complications, including recurrence, pain, and bulging. Quality of life was assessed with the European Registry for Abdominal Wall Hernias Quality of Life score. RESULTS: A total of 46 patients were identified. All patients underwent posterior component separation. Surgical site occurrences occurred in 10 patients (22%), with only 7 patients (15%) requiring procedural intervention. During a mean follow-up of 18 (range, 6-62), 1 (2%) case of clinical recurrence was registered. In addition, there were 8 (17%) patients with asymptomatic but visible bulging. The European Registry for Abdominal Wall Hernias Quality of Life score showed a statistically significant decrease in the 3 domains (pain, restriction, and cosmetic) of the postoperative compared with the preoperative scores. CONCLUSION: Posterior component separation technique for the repair of subcostal incisional hernias through the same incision is a safe procedure that avoids injury to the linea alba. It is associated with acceptable morbidity, low recurrence rate, and improvement in patients' reported outcomes.

Presentation of a large jejunal artery aneurysm: Management and review of the literature.

INTRODUCTION: Jejunal artery aneurysms (JAAs) constitute less than 1% of all visceral artery aneurysms. They affect mostly men in their fifth decade. In the last years, the widespread of fine cut fine image techniques has increased the number of JAAs diagnosed incidentally. The first case was reported by Levine in 1944. Since then, only a half of hundred cases have been reported. There is a lack of consensus of management of intact JAAs because of the low number of cases published. We present the largest JAA reported in the English literature up to our knowledge. PRESENTATION: We report a 49 year-old woman with a 4 × 5 cm. intact jejunal artery aneurysm found incidentally in a CT. It rose from the first jejunal branch of superior mesenteric artery without signs of rupture. She underwent elective surgery and the aneurysm was completely excised. DISCUSSION: Causes of JAAs include congenital, atherosclerosis or degenerative process. Their rate of rupture depends on location, size and underlying disease and it reaches 10-20% for all visceral artery aneurysms. Risk factors of rupture include pregnancy, hyper-flow situations and connective diseases. Most of cases in the literature presented rupture at the time of diagnosis. JAAs are usually treated following the recommendations for visceral artery aneurysms, so intact JAAs greater than 2 cm. and those causing symptoms should be treated. Treatment includes surgery, embolisation or stent. Surgery is the preferred management for emergency settings. CONCLUSION: JAAs are extremely rare and constitute only 1% of all visceral aneurysms. They are a life-threatening condition.

Hematoma espontáneo del músculo recto anterior del abdomen / Spontaneous haematoma of the anterior rectus abdominis muscle

INTRODUCCIÓN: El hematoma espontáneo del músculo recto del abdomen es una causa infrecuente de dolor abdominal que sucede con mayor frecuencia en pacientes anticoagulados. El objetivo de nuestro trabajo fue analizar la forma de presentación, el diagnóstico y los resultados del tratamiento en este grupo de pacientes. MÉTODOS: Análisis retrospectivo con una base de datos prospectiva de todos los casos de hematoma espontáneo del músculo recto del abdomen tratados en nuestro centro entre marzo de 2003 y diciembre de 2014. RESULTADOS: Se incluyó a 34 pacientes (25 mujeres) con una edad media de 80 años. En todos los casos el hematoma fue unilateral e infraumbilical. Veintiocho pacientes recibían tratamiento anticoagulante como parte de su tratamiento habitual (26 de ellos acenocumarol y 2 pacientes heparinas de bajo peso molecular a dosis terapéuticas). Seis pacientes recibían heparina de bajo peso molecular a dosis profilácticas. El diagnóstico se realizó mediante ecografía en 7 pacientes, tomografía axial computarizada con contraste intravenoso en fase arterial (angio-TC) en 27 y, con ambos métodos, en 6. El tratamiento consistió en la suspensión de la anticoagulación, corrección de la hemostasia y reposición hemática. En 10 pacientes se evidenció hemorragia activa en angio-TC y en 8 se realizó embolización selectiva. La evolución fue favorable en 32 pacientes. Dos pacientes fueron intervenidos debido a hemorragia grave persistente y fallecieron. CONCLUSIONES: El hematoma espontáneo del músculo recto del abdomen es más frecuente en mujeres de edad avanzada y en tratamiento con anticoagulantes orales. La mayoría evolucionan favorablemente con tratamiento no operatorio. La angio-TC es útil para indicar la embolización arterial selectiva en caso de hemorragia activa

INTRODUCTION: Spontaneous haematoma of the rectus abdominis muscle is an uncommon cause of abdominal pain. It occurs mostly in anticoagulated patients. The objective of this paper is to analyse the onset, diagnosis and treatment in patients under anticoagulant therapy. METHODS: A retrospective analysis of a prospectively maintained database of all patients with a diagnosis of spontaneous hematoma of the abdominal rectus muscle between March 2003 and December 2014. RESULTS: The study included 34 patients, of whom 28 were women, with an average age of 80 years old. All the patients showed a unilateral infraumbilical haematoma. Twenty- 8 patients had received long-term anticoagulant treatment (26 with acenocumarol and 2 low molecular weight heparin); and 6 patients were under anticoagulant prophylaxis with low molecular weight heparin. The diagnosis was performed with ultrasound in 7 cases, computed tomography angiography in 27 patients, and with both methods in 6 cases. The treatment consisted of stopping the anticoagulant drug, correcting haemostasis parameters and blood transfusion when required. Ten patients displayed active bleeding in the computed tomography angiography, and 8 underwent selective arterial embolization. The evolution was successful in 34 patients, however, 2 patients required surgery and, finally, died due to persistent haemorrhage. CONCLUSION: Spontaneous haematoma of the rectus abdominis muscle is more frequent in elderly women under oral anticoagulant treatment. Non-operative treatment is successful in most cases. Computed tomography angiography is useful to determine which patients could benefit from selective arterial embolization

Spontaneous haematoma of the anterior rectus abdominis muscle. / Hematoma espontáneo del músculo recto anterior del abdomen.

INTRODUCTION: Spontaneous haematoma of the rectus abdominis muscle is an uncommon cause of abdominal pain. It occurs mostly in anticoagulated patients. The objective of this paper is to analyse the onset, diagnosis and treatment in patients under anticoagulant therapy. METHODS: A retrospective analysis of a prospectively maintained database of all patients with a diagnosis of spontaneous hematoma of the abdominal rectus muscle between March 2003 and December 2014. RESULTS: The study included 34 patients, of whom 28 were women, with an average age of 80 years old. All the patients showed a unilateral infraumbilical haematoma. Twenty- 8 patients had received long-term anticoagulant treatment (26 with acenocumarol and 2 low molecular weight heparin); and 6 patients were under anticoagulant prophylaxis with low molecular weight heparin. The diagnosis was performed with ultrasound in 7 cases, computed tomography angiography in 27 patients, and with both methods in 6 cases. The treatment consisted of stopping the anticoagulant drug, correcting haemostasis parameters and blood transfusion when required. Ten patients displayed active bleeding in the computed tomography angiography, and 8 underwent selective arterial embolization. The evolution was successful in 34 patients, however, 2 patients required surgery and, finally, died due to persistent haemorrhage. CONCLUSION: Spontaneous haematoma of the rectus abdominis muscle is more frequent in elderly women under oral anticoagulant treatment. Non-operative treatment is successful in most cases. Computed tomography angiography is useful to determine which patients could benefit from selective arterial embolization.

Large cell neuroendocrine - Adenocarcinona mixed tumour of colon: Collision tumour with peculiar behaviour. What do we know about these tumours?

INTRODUCTION: Mixed glandular-endocrine carcinomas are rare tumours of gastrointestinal tract (MANEC). They are more frequent in stomach and hardly one hundred cases have been described in colon. According to Lewis, they are classified into collision (side by side pattern), composite (intermingled) or amphicrine (neuroendocrine and glandular features inside a same cell). Collision tumours are related to biclonal theory: two simultaneous cancerogenic events. Conversely, multidirectional differentiation from a stem cell is accepted as origin of composite tumours. The aim of this paper is to analyse the behaviour of these tumours, with an especial concern about how these tumours metastasise, and the different theories about carcinogenesis. PRESENTATION OF CASE: We report a rare case of collision adenocarcinoma-large cell neuroendocrine tumour of colon that after a three-year period of follow-up has presented a retroperitoneal recurrence that features adenocarcinoma and large cell neuroendocrine components. DISCUSSION: After an exhaustive review of the English literature, we found that only two cases of collision tumour of colon with metastases showing glandular and endocrine components have been described up to date, so we report the third case, and the first happening in transverse colon. CONCLUSION: We conclude that not all collision tumours follow the biclonal theory and more studies are needed to clarify the origin of these neoplasms, and consequently, to reach an adequate treatment.

Ileocolic intussusception due to giant ileal lipoma: Review of literature and report of a case.

INTRODUCTION: Intussusception in adults accounts for less than 5% of all intussusceptions. It occurs when a segment of intestine invaginates into itself. PRESENTATION OF A CASE: We report a case of ileocolic intussusception in an adult caused by a giant ileal lipoma. DISCUSSION: Intussusceptions can be classified as ileocolic, ileocecal, colo-colic and ileo-ileal. Most are due to neoplasms (60% malign and 24-40% benign). In the colon, the possibility of malignancy is higher than in small intestine. Lipomas are the most common benign mesenchymal intestinal tumors, accounting for less than 5% of all gastrointestinal tumors. They are more frequent in colon than small intestine. Small lipomas (less than 2cm) are usually asymptomatic. Larger lesions may produce symptoms such as abdominal pain, obstruction or intussusception. Lipomas can be diagnosed with endoscopy, capsule endoscopy, barium enemas, CT and US. CONCLUSION: Intussusceptions in adults is a rare condition, most of them are caused by a malign neoplasms followed by benign neoplasms. US and CT are useful for diagnosis. Surgery is mandatory.

Two rare cases of intrahepatic subcapsular hematoma after laparoscopic cholecystectomy.

The appearance of subcapsular liver hematoma after a laparoscopic cholecystectomy (LC) is an infrequent complication and seldom studied. Some cases have been connected to ketorolac given during surgery and after surgery. Other described causes are : hemangiomas or small iatrogenic lesions that could be aggravated by administration of ketorolac. Coagulation dysfunction like circulating heparin as seen in hemathological diseases is cause of bleeding after aggressive procedures. We describe two cases of subcapsular liver hematoma after LC, both of them have been given intravenous ketorolac and one of them had multiple myeloma. We discuss the causes and treatment of it.