Manejo laparoscópico de una obstrucción de intestino delgado ocasionada por un foco endometriósico / Laparoscopic management of a small bowel obstruction caused by an endometriotic focus

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Laparoscopic management of a small bowel obstruction caused by an endometriotic focus.

Endometriosis is the presence of extra-uterine endometrial tissue and affects 6-10% of fertile women. In 3-37% of the cases it affects the gastrointestinal tract being the ileal location extremely infrequent. Symptoms are nonspecific, debuting as intestinal obstruction in 7-23% of cases. The definitive diagnosis is anatomopathological and the treatment in these cases of acute abdomen is surgery. We attach the present case due to its rarity, it is a young asymptomatic woman who debuts with a picture of intestinal obstruction that is treated by intestinal resection via laparoscopy confirming the endometriosis etiology.

Una complicación rara tras la realización de una colonoscopia: la lesión esplénica / A rare complication after colonoscopy: a splenic rupture

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A rare complication after colonoscopy: a splenic rupture.

Colonoscopy is the gold standard for the study of colorectal pathology. Splenic injury is a rare but potentially fatal complication to consider. Therefore, we present two cases whose management was different and we show their clinical presentation, their diagnosis and their treatment in order to recognize this complication early to establish early treatment.

[Giant splenic cyst in a teenager girl: Case report]. / Quiste esplénico gigante en una adolescente: Caso clínico.

Giant nonparasitic splenic epidermoid cysts are relatively uncommon. These lesions can lead abdominal pain, but most of then are asymptomatic, and they are discovered incidentally. We report a 13-y old female with a giant splenic epidermoid cystic, given the special interest of diagnostic and therapeutic decision-making of this rare entity. CASE REPORT: A 13-y old female with clinical history of abdominal pain since the last two months. On physical examination a firm, tender mass was palpable in left hypochondrium. Diagnosis of a large cystic splenic mass was made based on ultrasound and abdominal computed tomography scan. Splenectomy was performed, and histopathological-immunohistochemistry studies revealed findings suggestive of primary epithelial cyst. The post-operative clinical course was satisfactory and uneventful. CONCLUSIONS: Treatment of giant nonparasitic splenic cysts is surgical. Preserve splenic parenchyma must be the aim in an individualized decision-making. The different types of surgical modalities will be according to the diagnosis and clinical situation (cyst size, age, comorbidities).

Quiste esplénico gigante en una adolescente: Caso clínico / Giant splenic cyst in a teenager girl: Case report

Los quistes esplénicos gigantes y no parasitarios son infrecuentes. Estas lesiones pueden manifestarse como dolor abdominal, si bien a menudo son asintomáticas y se diagnostican en forma incidental. Objetivo: Presentar el caso de un quiste esplénico epitelial gigante por su interés en la toma de decisiones diagnósticas y terapéuticas, al ser una entidad muy poco frecuente.
 Caso clínico: Paciente de sexo femenino de 13 años de edad que consultó por dolor abdominal de dos meses de evolución. En la exploración física se palpaba una masa de consistencia dura en hemiabdomen izquierdo. En los estudios de imágenes se visualizó una masa esplénica quística gigante. Se realizó esplenectomía obteniendo un quiste subcapsular que comprometía la mayor parte del bazo, el estudio anatomopatológico e inmunohistoquímico fueron compatible con quiste epitelial. La evolución postoperatoria y el posterior seguimiento ambulatorio fueron favorables. Conclusiones: El tratamiento de los quiste esplénicos gigantes no parasitarios es quirúrgico, intentando conservar, en lo posible, la mayor cantidad de tejido esplénico. Este procedimiento debe ser individualizado, considerando el tamaño, las posibilidades diagnósticas, el tejido esplénico residual, la edad del paciente y comorbilidades.

Giant nonparasitic splenic epidermoid cysts are relatively uncommon. These lesions can lead abdominal pain, but most of then are asymptomatic, and they are discovered incidentally. We report a 13-y old female with a giant splenic epidermoid cystic, given the special interest of diagnostic and therapeutic decision-making of this rare entity. Case report: A 13-y old female with clinical history of abdominal pain since the last two months. On physical examination a firm, tender mass was palpable in left hypochondrium. Diagnosis of a large cystic splenic mass was made based on ultrasound and abdominal computed tomography scan. Splenectomy was performed, and histopathological-immunohistochemistry studies revealed findings suggestive of primary epithelial cyst. The post-operative clinical course was satisfactory and uneventful. Conclusions: Treatment of giant nonparasitic splenic cysts is surgical. Preserve splenic parenchyma must be the aim in an individualized decision-making. The different types of surgical modalities will be according to the diagnosis and clinical situation (cyst size, age, comorbidities).

Early and Late Complications in Laparoscopic Gastric Bypass: Comparative Study between Manual and Stapled Anastomosis.

The aim of this study is to evaluate the early and late complications of laparoscopic gastric bypass (GBP) with manual versus stapled gastrojejunal anastomosis. Eighty-two patients with morbid obesity and body mass index (35-56 kg/m2) who underwent GBP were divided into two groups: manual gastrojejunal anastomosis (Group 1) and stapled anastomosis (Group 2). Early and late complications were evaluated. No differences were found between both groups in age, sex, body mass index, American Society of Anesthesia classification, and comorbidity. The mean operative time was 184.8 minutes [standard deviation (SD) = 61]; 203.5 minutes (SD = 51.9) in Group 1 and 167.4 minutes (SD = 64.2) in Group 2 (P = 0.001). The average length of stay was 5.9 days (SD = 3.9) in Group 1 and 5 days (SD = 2.1) in Group 2 (P = 0.039). Early complications were recorded in 9.7 per cent of the cases, without any differences between the two groups: 12.2 per cent in Group 1 and 7.3 per cent in Group 2 (P > 0.05). Late complication rate was 8.5 per cent, significantly higher in Group 1 (14.6%) than in Group 2 (2.4%; P < 0.05). However, in the logistic regression analysis these differences were not statistically significant (OR 0.48; 95% CI 0.03-8.37; P = 0.61). In our series, the GBP with stapled gastrojejunal anastomosis has shown lower hospital length of stay and operative time than the hand-sewn anastomosis. We have not found significant differences between both groups in early complications or in the need for reoperation. Fewer late complications were found in the group of stapled anastomosis; however, this has not been confirmed in the logistic regression analysis.

[Cervical sympathetic chain schwannoma associated with parathyroid adenoma]. / Schwannoma de la cadena simpática cervical asociado a adenoma paratiroideo.

BACKGROUND: Schwannoma is a rare benign tumor derived from nerve sheaths. When derived from the cervical sympathetic chain, it usually presents itself as an asymptomatic mass located in the posterior cervical region, at paravertebral level. Its diagnosis is not easy, usually requiring multiple imaging tests. Its differential diagnosis includes parathyroid adenoma. CLINICAL CASE: A new case of schwannoma of the cervical sympathetic chain in a patient with a synchronous overactive parathyroid adenoma is reported. This case adds to the sixty described in the literature, although to our knowledge no association between schwannoma and parathyroid adenoma has been reported to date. CONCLUSIONS: Despite being a benign tumor, its treatment is a complete surgical resection. The most common complication after the surgery needed for these tumors is ipsilateral Horner syndrome.

[Appendicovesical fistula treated with elective laparoscopic surgery]. / Fístula apendicovesical tratada mediante cirugía laparoscópica electiva.

BACKGROUND: appendicovesical fistula is a rare complication of advanced acute appendicitis and represents a rare type of enterovesical fistula. Its symptoms are vague and imprecise and its diagnosis is difficult, requiring a high level of suspicion. Exploratory laparotomy has been the key for diagnosis and definitive treatment for many years, but recently the laparoscopic approach is standing out among different experienced groups as the method of choice. CLINICAL CASE: we report a new case of appendicovesical fistula in a 45 year old female, who was remitted from Urology with symptoms of persistent dysuria and pyuria. She was finally diagnosed by computerized tomography and the appendicovesical fistula was resolved by laparoscopic surgery. This case adds to the one hundred and fifteen cases published so far and to the four treated by the laparoscopic approach. DISCUSSION: conventional imaging methods are not reliable for the diagnosis of enterovesical fistula. Since most appendicovesical fistula are found to be secondary to non-diagnosed and advanced acute appendicitis in the majority of the consulted publications laparotomy is the key for the diagnosis of apendicovesical fistula. However laparoscopy is described as a diagnostic and therapeutic tool in few articles. We only found three articles in the literature referring to the laparoscopic approach as a therapeutic option. CONCLUSION: computerized tomography is the diagnostic method of choice when communication between the digestive tract and urinary tract is suspected, particularly if the suspected fistula is an appendicovesical one. The laparoscopic approach of an appendicovesical fistula is able to confirm the radiological diagnosis and provide a definitive treatment.

Antecedentes: la fístula apendicovesical es una complicación infrecuente de la apendicitis aguda en estadio avanzado y representa un tipo poco habitual de fístula enterovesical. La laparotomía exploradora ha sido durante muchos años pieza clave para el diagnóstico y su tratamiento efinitivo, pero actualmente el abordaje laparoscópico se está imponiendo entre diferentes grupos experimentados. Caso clínico: aportamos un nuevo caso de fístula apendicovesical en una mujer de 45 años de edad remitida del servicio de Urología por disuria y leucocituria permanente; finalmente, el diagnóstico se estableció mediante técnica de imagen (tomografía computada) y se resolvió por laparoscopia. Este caso se suma a los 115 casos descritos hasta ahora en la bibliografía y a los cuatro tratados mediante laparoscopia. Discusión: los métodos de imagen convencionales no son fiables para el diagnóstico de fístula enterovesical. La mayoría de los casos de fístula apendicovesical son secundarios a una apendicitis aguda no evidenciada y evolucionada. En la mayor parte de las publicaciones consultadas la laparotomía es una herramienta de diagnóstico de la fístula apendicovesical y, en pocos artículos, se describe la laparoscopia como alternativa diagnóstica y terapéutica. En la bibliografía sólo se encontraron tres artículos que hacen referencia al abordaje laparoscópico con fines terapéuticos. Conclusión: ante la sospecha de comunicación entre el tubo digestivo y el aparato urinario, la tomografía computada es el método diagnóstico de elección, sobre todo si se sospecha una fístula apendicovesical. El abordaje laparoscópico de la fístula apendicovesical puede confirmar el diagnóstico radiológico a la vez que constituye una opción quirúrgica definitiva.

Modificaciones anatomofuncionales del corazón en la obesidad mórbida. Cambios tras la cirugía bariátrica / Anatomical and functional alterations of the heart in morbid obesity. Changes after bariatric surgery

Introducción y objetivos. La adaptación cardiaca a la obesidad asocia anomalías estructurales y funcionales del corazón. El último escalón terapéutico en la obesidad mórbida lo ofrece la cirugía bariátrica. En este estudio se investigan los cambios anatomofuncionales del corazón en una cohorte española de obesos mórbidos y las modificaciones después de la cirugía bariátrica. Métodos. Inclusión prospectiva de pacientes referidos para cirugía bariátrica. En cada caso se realizó ecocardiograma transtorácico, electrocardiograma y analítica antes de la cirugía y 1 año después de la intervención. Resultados. Alcanzaron el seguimiento a 1 año 41 pacientes, con media de edad de 40,2±9,6 años, el 82,9% mujeres. El índice de masa corporal promedio era 47,41, y pasó a 30,43 después de la cirugía. Antes de la cirugía, el 70,7% presentaba remodelado ventricular, fundamentalmente por hipertrofia excéntrica (el 34,1% de los casos). Al año, el 58,5% tenía un patrón geométrico normal (p = 0,02). La relación E/A de llenado mitral pasó de 1,14 a 1,43 (p<0,001). Sin embargo, la velocidad del anillo mitral medida con Doppler tisular descendió ligeramente (p=0,06). Conclusiones. Los pacientes obesos mórbidos que se someten a cirugía bariátrica presentan con elevada frecuencia datos de remodelado ventricular, que es fundamentalmente de características excéntricas. La pérdida de peso conseguida mediante cirugía bariátrica se acompaña de significativas mejorías estructurales y en muchos casos lleva a la normalización completa del patrón geométrico ventricular. Sin embargo, es posible que la disfunción diastólica llegue a ser permanente (AU)

Introduction and objectives. Cardiac adaptation to obesity includes both structural and functional changes in the heart. The therapeutic option of last resort for morbidly obese patients is bariatric surgery. This study aims to assess the anatomical functional changes in the heart for a Spanish cohort of morbidly obese patients, as well as changes after bariatric surgery. Methods. Patients referred for bariatric surgery were prospectively included. In each case, a transthoracic echocardiography, electrocardiogram, and blood tests were performed before the procedure and repeated 1 year after surgery. Results. Forty-one patients completed the 1-year follow-up. Of these, 82.9% were female. Mean age was 40.2±9.6) years. Prior to surgery, mean body mass index was 47.41kg/m2, decreasing to 30.43kg/m2 after the procedure. Before surgery, cardiac remodeling was present in 70.7%, most frequently in the form of eccentric hypertrophy (34.1%). At 1-year follow-up, 58.5% showed a normal left ventricular geometric pattern (P=.02). Mitral inflow E/A ratio changed from 1.14 to 1.43 (P<.001). Nevertheless, early mitral velocity measured by Doppler tissue decreased (P=.06). Conclusions. In morbidly obese patients referred for bariatric surgery, cardiac remodeling is highly prevalent, in most cases in an eccentric manner. Weight loss achieved by bariatric surgery is accompanied by significant improvements in left ventricular structure. Nevertheless, the damage in diastolic function may be permanent despite weight loss (AU)

Anatomical and functional alterations of the heart in morbid obesity. Changes after bariatric surgery.

INTRODUCTION AND OBJECTIVES: Cardiac adaptation to obesity includes both structural and functional changes in the heart. The therapeutic option of last resort for morbidly obese patients is bariatric surgery. This study aims to assess the anatomical functional changes in the heart for a Spanish cohort of morbidly obese patients, as well as changes after bariatric surgery. METHODS: Patients referred for bariatric surgery were prospectively included. In each case, a transthoracic echocardiography, electrocardiogram, and blood tests were performed before the procedure and repeated 1 year after surgery. RESULTS: Forty-one patients completed the 1-year follow-up. Of these, 82.9% were female. Mean age was 40.2±9.6 years. Prior to surgery, mean body mass index was 47.41 kg/m(2), decreasing to 30.43 kg/m(2) after the procedure. Before surgery, cardiac remodeling was present in 70.7%, most frequently in the form of eccentric hypertrophy (34.1%). At 1-year follow-up, 58.5% showed a normal left ventricular geometric pattern (P=.02). Mitral inflow E/A ratio changed from 1.14 to 1.43 (P<.001). Nevertheless, early mitral velocity measured by Doppler tissue decreased (P=.06). CONCLUSIONS: In morbidly obese patients referred for bariatric surgery, cardiac remodeling is highly prevalent, in most cases in an eccentric manner. Weight loss achieved by bariatric surgery is accompanied by significant improvements in left ventricular structure. Nevertheless, the damage in diastolic function may be permanent despite weight loss.