Life-threating upper gastrointestinal bleeding due to a primary aorto-jejunal fistula.

INTRODUCTION: Primary aorto-enteric fistula (AEF) is an uncommon life-threating condition. Only 4% of them involve the jejunum or ileum and its mortality ranges from 33 to 85%. PRESENTATION OF CASE: A 54-year-old female was admitted to the Emergency Department with syncope and hematemesis. The esophagogastroduodenoscopy found a pulsatile vessel in the second portion of the duodenum. A computed tomography scan showed an AEF with an infrarenal aortic aneurysm and iliac artery thrombosis. During surgery, an infrarenal aortic aneurysm complicated with an aorto-jejunal fistula was found. An axilo-bifemoral bypass, open repair of the aneurysm and segmental small bowel resection with primary suture of the jejunal defect were performed. DISCUSSION: Depending on previous aortic grafting, AEF can be classified as primary or secondary. Primary AEF is usually caused by an untreated abdominal aortic aneurysm, commonly presenting an infectious etiology. The main clinical sign is a "herald" hemorrhage. The EGD is considered as the first step in diagnosing AEF. The treatment of choice for AEF is emergent surgery. Use of broad-spectrum antibiotics is mandatory in the postoperative period to avoid fistula recurrence. CONCLUSION: AEF is a rare entity with a high mortality. High clinical suspicion is essential to make a correct diagnosis, which is crucial for the prognosis of these patients, such is the case of our patient. If hemodynamic stability is achieved, it allows to employ surgical strategies in which extra-abdominal bypass is performed before fistula is treated.

Single-port transumbilical laparoscopic cholecystectomy: A prospective randomised comparison of clinical results of 140 cases.

INTRODUCTION: A novel single port access (SPA) cholecystectomy approach is described in this study. We have designed a randomised comparative study in order to elucidate any possible differences between the standard treatment and this novel technique. MATERIALS AND METHODS: Between July 2009 and March 2010, 140 adult patients with gallbladder pathologies were enrolled in this multicentre study. Two surgeons (RV and UB) randomised patients to either a standard laparoscopic (SL) approach group or to an SPA cholecystectomy group. Two types of trocars were used for this study: the TriPort™ and the SILS™ Port. Outcomes including blood loss, operative time, complications, length of stay and pain were recorded. RESULTS: There were 69 patients in the SPA group and 71 patients in the SL group. The mean age of the patients was 43.2 (17-77) for the SPA group and 42.6 (19-70) for the SL group. The mean operative time was 63.9 min in the SPA group and 58.4 min in the SL group. For one patient, the SPA procedure was converted to a standard laparoscopic technique and to open approach in the SL group. Complications occurred in eight patients: Five seromas (two in the SPA group) and three hernias (one in the SPA group).The mean hospital stay was 38.5 h in the SPA group and 24.1 h in the SL group. Pain was evaluated and was 2 in the SPA and 2.9 in the SL group, according to the visual analogue scale (VAS) after 24 h (P<0.001). The degree of satisfaction was higher in the SPA group (8.3 versus 6.7). Similar results were found for the aesthetic result (8.8 versus 7.5). (P<0.001). CONCLUSION: Single-port transumbilical laparoscopic cholecystectomy can be feasible and safe. When technical difficulties arise, early conversion to a standard laparoscopic technique is advised to avoid serious complications. The SPA approach can be undertaken without the expense of additional operative time and provides patients with minimal scarring. The cosmetic results and the degree of satisfaction appear to be significant for the SPA approach.

Post traumatic splenic function depending on severity of injury and management.

Because splenectomy has been linked to overwhelming infection years ago, management of splenic traumatisms has become progressively conservative. To assess the immunological function of the spleen in patients with splenic traumatism of different intensity, 43 patients with splenic injury (grades I through V) undergoing either nonoperative management, splenectomy, splenectomy with autotransplantation, or splenic embolization were analyzed for lymphocyte subpopulations and antibody responses to Streptococcus pneumoniae and Haemophilus influenzae vaccinations. Patients treated with splenectomy exhibited a significant decrease in CD4+ T lymphocytes and in Immunoglobulin (Ig) M(high)IgD(low) B cells (related to T-cell independent responses). Median fluorescence intensity of CD54+ in B cells also was reduced. The percent of IgM(high)IgD(low) B cells-a marker of marginal zone function-was inversely correlated with the number of pitted-red blood cells-a marker of red pulp function loss. IgM anti-S pneumoniae identified those patients with a defective rapid response to polysaccharide antigens. These results reinforce the importance of conservative options in the treatment of splenic traumatism for even a severely damaged organ. Despite the significant differences among the groups reported, it remains difficult to predict the IgM response to S pneumoniae vaccine of the individual patients. Better markers to assess splenic function and vaccination response after severe splenic traumatism-even in patients with nonoperative management-might improve risk assessment for overwhelming postsplenectomy infection.

[Evaluation of splenic function by dynamic gammagraphy, study of pitted erythrocytes and submembranous vacuoles in patients with slight and severe splenic trauma receiving conservative treatment or splenectomy]. / Valoración de la función esplénica mediante gammagrafía dinámica y estudio de "pits" de la membrana eritrocitaria y de vacuolas submembranarias en los pacientes con traumatismo leve y grave de bazo tratados de forma conservadora o mediante esplenectomía.

BACKGROUND AND OBJECTIVE: The splenic function of patients followed by the Department of General and Digestive Surgery in the Hospital Universitari Germans Trias i Pujol (HUGTiP) from 1985 to 2003 for different degrees of splenic trauma according to the classification of the American Association for the Surgery of Trauma (AAST) 1994 was quantified and related to the treatment received (non surgical, total splenectomy with or without splenosis and splenectomy plus autotransplantation) to detect splenic dysfunction predisposing the development of postsplenectomy sepsis (PSS). PATIENTS AND METHOD: 43 patients underwent an isotopic study with dynamic splenic gammagraphy and pitted erythrocytes (Normarsky optics) and submembranous vacuoles (transmission electron microscopy) were evaluated. RESULTS: The non surgical group presented normal phagocytic and filtration function with the median speed of splenic enhancement being 3.46 Kcts/s2 (interval: 0.8-6.98). The percentage of pitted erythrocytes was 2% (0-8.8), the number of pits per erythrocyte was 0.03 (0-0.12) and the percentage of erythrocytes with 1, 2, 3 and 4 pits was 1.6%, 0.4%, 0% and 0%, respectively. The percentage of red cells with submembranous vacuoles was 2.55% (0-5.6), the number of vacuoles per red cell was 0.03 (0-0.06) and the percentage of red cells with 1, 2, 3 and 4 vacuoles was 2%, 0.2%, 0% and 0%, respectively. In the operated group, the splenic enhancement speed was 0.08 Kcts/s2 (0-1.75) (p < 0.0001). The percentage of pitted erythrocytes was 38% (0.2-64) (p < 0.0001), the number of pits per erythrocyte was 0.86 (0-1.8) (p < 0.0001) and the percentage of erythrocytes with 1,2,3 and 4 pits was 16.39%, 7.2%, 3.59% and 2.52%, respectively (p < 0.0001). The percentage of red cells with submembranous vacuoles was 11.2% (1.8-31.9) (p = 0.0006); the number of vacuoles per cell was 0.16 (p = 0.0022) and the percentage of red cells with 1, 2, 3 and 4 vacuoles was 6.51%, 1.73%, 0.4% and 0.2%, respectively (p = 0.0246, 0.0010, < 0.0001 and 0.0002, respectively). CONCLUSIONS: Splenic function of patients with a history of splenic trauma receiving conservative treatment is normal, independently of the degree of the lesion, thereby reinforcing the use of this therapeutic approach to avoid the development of postsplenectomy sepsis. In the patients treated with splenectomy, with or without splenosis, splenic function was absent or very altered being partially conserved in cases treated with splenectomy plus autotransplantation.

Valoración de la función esplénica mediante gammagrafía dinámica y estudio de «pits» de la membrana eritrocitaria y de vacuolas submembranarias en los pacientes con traumatismo leve y grave de bazo tratados de forma conservadora o mediante esplenectomía / Evaluation of splenic function by dynamic gammagraphy, study of pitted erythrocytes and submembranous vacuoles in patients with slight and severe splenic trauma receiving conservative treatment or splenectomy

Fundamento y objetivo: Cuantificar la función esplénica de los pacientes controlados en el Servicio de Cirugía General y Digestiva del Hospital Universitari Germans Trias i Pujol (HUGTiP) desde 1985 hasta 2003 tras haber sufrido diferentes grados de lesión traumática del bazo según la clasificación de la American Association for the Surgery of Trauma (AAST) del año 1994 y relacionarla con el tratamiento recibido (no operatorio, esplenectomía total con o sin esplenosis y esplenectomía más autotrasplante), con la finalidad de detectar disfunciones esplénicas que predispongan al desarrollo de la sepsis tras la esplenectomía. Pacientes y método: Se ha realizado a 43 pacientes un estudio isotópico con gammagrafía esplénica «dinámica», estudio de «pits» de la membrana eritrocitaria (óptica de Nomarsky) y de vacuolas submembranarias (microscopia electrónica de transmisión). Resultados: El grupo de no operados presenta una función normal de fagocitosis y filtración, con una mediana de velocidad de captación esplénica de 3,46 Kcts/s2 (intervalo, 0,8-6,98). El porcentaje mediano de «pits» de membrana fue del 2% (intervalo, 0-8,8%); el número de «pits» por hematíes, de 0,03 (intervalo, 0-0,12), y el porcentaje de hematíes con 1, 2, 3 y 4 «pits», del 1,6, el 0,4, el 0 y el 0%, respectivamente. El porcentaje mediano de hematíes con vacuolas submembranarias fue el 2,55% (intervalo, 0-5,6%); el número de vacuolas por hematíe, de 0,03 (intervalo, 0-0,06), y el porcentaje de hematíes con 1, 2, 3 y 4 vacuolas, del 2, el 0,2, el 0 y el 0%, respectivamente. En el grupo operado, la velocidad mediana de captación esplénica fue de 0,08 Kcts/s2 (intervalo, 0-1,75; p < 0,0001); el porcentaje mediano de «pits» de membrana, del 38% (intervalo, 0,2-64; p < 0,0001); el número mediano de «pits» por hematíe, de 0,86 (intervalo, 0-1,8; p < 0,0001), y el porcentaje de hematíes con 1, 2, 3 y 4 «pits», del 16,39, el 7,2, el 3,59 y el 2,52%, respectivamente (p < 0,0001). La mediana del porcentaje de hematíes con vacuolas submembranarias fue del 11,2% (intervalo, 1,8-31,9; p = 0,0006); el número mediano de vacuolas por hematíe, de 0,16 (p = 0,0022), y el porcentaje de hematíes con 1, 2, 3 y 4 vacuolas, del 6,51, el 1,73, el 0,4 y el 0,2%, respectivamente (p = 0,0246; p = 0,0010; p < 0,0001, y p = 0,0002, respectivamente). Conclusiones: La función esplénica de los pacientes con antecedentes de traumatismo esplénico tratados de forma conservadora es normal, independientemente del grado de la lesión. Ello refuerza la conveniencia de aplicar de entrada esta actitud a todos los protocolos para intentar evitar la sepsis tras la esplenectomía. En los casos tratados con esplenectomía, con o sin esplenosis, la función esplénica está ausente o muy alterada, mientras que en los casos tratados con esplenectomía y autotrasplante está parcialmente conservada

Background and objective: The splenic function of patients followed by the Department of General and Digestive Surgery in the Hospital Universitari Germans Trias i Pujol (HUGTiP) from 1985 to 2003 for different degrees of splenic trauma according to the classification of the American Association for the Surgery of Trauma (AAST) 1994 was quantified and related to the treatment received (non surgical, total splenectomy with or without splenosis and splenectomy plus autotransplantation) to detect splenic dysfunction predisposing the development of postsplenectomy sepsis (PSS). Patients and method: 43 patients underwent an isotopic study with dynamic splenic gammagraphy and pitted erythrocytes (Normarsky optics) and submembranous vacuoles (transmission electron microscopy) were evaluated. Results: The non surgical group presented normal phagocytic and filtration function with the median speed of splenic enhancement being 3.46 Kcts/s2 (interval: 0.8-6.98). The percentage of pitted erythrocytes was 2% (0-8.8), the number of pits per erythrocyte was 0.03 (0-0.12) and the percentage of erythrocytes with 1,2,3 and 4 pits was 1.6%, 0.4%, 0% and 0%, respectively. The percentage of red cells with submembranous vacuoles was 2.55% (0-5.6), the number of vacuoles per red cell was 0.03 (0-0.06) and the percentage of red cells with 1,2,3 and 4 vacuoles was 2%, 0.2%, 0% and 0%, respectively. In the operated group, the splenic enhancement speed was 0.08 Kcts/s2 (0-1.75) (p < 0.0001). The percentage of pitted erythrocytes was 38% (0.2-64) (p < 0.0001), the number of pits per erythrocyte was 0.86 (0-1.8) (p < 0.0001) and the percentage of erythrocytes with 1,2,3 and 4 pits was 16.39%, 7.2%, 3.59% and 2.52%, respectively (p < 0.0001). The percentage of red cells with submembranous vacuoles was 11.2% (1.8-31.9) (p = 0.0006); the number of vacuoles per cell was 0.16 (p = 0.0022) and the percentage of red cells with 1,2,3 and 4 vacuoles was 6.51%, 1.73%, 0.4% and 0.2%, respectively (p = 0.0246, 0.0010, < 0.0001 and 0.0002, respectively). Conclusions: Splenic function of patients with a history of splenic trauma receiving conservative treatment is normal, independently of the degree of the lesion, thereby reinforcing the use of this therapeutic approach to avoid the development of postsplenectomy sepsis. In the patients treated with splenectomy, with or without splenosis, splenic function was absent or very altered being partially conserved in cases treated with splenectomy plus autotransplantation