Endometriosis apendicular. Nuestra experiencia en los últimos 11 años / Appendiceal endometriosis. A retrospective analysis of 11 years’ experience

Introducción y objetivos: La endometriosis es una enfermedad con una incidencia que puede llegar al 50% en mujeres en edad fértil. La endometriosis apendicular se presenta en el 1% de estas pacientes, con una clínica variable: su presentación más frecuente es la propia de una apendicitis. El objetivo del estudio es describir y analizar las características clínicas y anatomopatológicas de los casos de endometriosis apendicular de los últimos 10años en el Hospital 12 de Octubre. Pacientes y métodos: Presentamos el estudio retrospectivo de los casos de endometriosis apendicular de nuestro centro en los últimos 10 años. Resultados: Encontramos 22 casos de endometriosis apendicular de un total de 7.051 piezas. La mediana de edad de las pacientes fue de 38,5 años, con 3 pacientes fuera de edad fértil. El inicio fue un abdomen agudo en 16 pacientes; hasta en 10 casos se requirió la realización de 2pruebas de imagen. La endometriosis apendicular fue sospechada en tan solo 2 pacientes. El abordaje laparoscópico fue la técnica de preferencia en los casos crónicos o dudosos. En 6 de las piezas apareció una apendicitis concomitante. Conclusiones: La endometriosis apendicular presenta un difícil diagnóstico preoperatorio y debe ser tenida en cuenta en el diagnóstico diferencial de la apendicitis aguda y considerar que puede ocurrir fuera de la edad fértil

Introduction and objectives: Endometriosis is a disease with an incidence that may reach 50% in women of childbearing age. Appendiceal endometriosis occurs in 1% of these patients. Although symptoms vary, it typically manifests with the same symptoms as appendicitis. The aim of this study was to describe and analyse the clinical, anatomical and pathological characteristics of the appendiceal endometriosis cases treated over the last decade at 12 de Octubre Hospital. Patients and methods: We present a retrospective study of the cases of appendiceal endometriosis treated at our centre over the last 10 years. Results: We found 22 cases of appendiceal endometriosis from a total of 7051 cases. Median patient age was 38.5 years, with 3 patients not of childbearing age. Acute abdomen was the initial manifestation in 16 patients, requiring the performance of 2imaging tests in 10 cases. Appendiceal endometriosis was suspected in only 2 patients. The laparoscopic approach was the preferred technique in chronic or doubtful cases. Concomitant appendicitis was found in 6cases. Conclusions: Appendiceal endometriosis presents a preoperative diagnostic challenge and should be considered in the differential diagnosis of acute appendicitis, bearing in mind that it can arise in women not of childbearing age

Migración rectal de dispositivo intrauterino / Rectal migration of intrauterine device

Fundamento y objetivo: Los dispositivos intrauterinos (DIU), constituyen el 23% del uso general de las medidas contraceptivas reversibles en todo el mundo. Entre las complicaciones más graves secundarias a su uso, destacan la perforación uterina y la migración del dispositivo. Material y método: Se presenta un caso de migración de DIU a través de pared rectal en una mujer de 40 años, que acude al servicio de urgencias por dolor brusco y rectorragia. A la exploración física se objetiva el componente horizontal del DIU saliendo a través del orificio anal y mediante tacto rectal se palpa el componente vertical alojado en recto; localización que se verifica mediante la realización de una TC abdominopélvica. En este caso, se realizó una extracción colonoscópica del cuerpo extraño. Conclusiones: En general, cuando una perforación es identificada, se recomienda la extracción del dispositivo lo antes posible. Para ello se pueden usar técnicas endoscópicas o quirúrgicas, en función de la localización, por lo que cada caso debe ser individualizado

Background and objectives: Intrauterine devices (IUDs) constitutes the 23% of the general use of reversible contraceptive measures in the world. Among the most serious complications secondary to its use include uterine perforation and migration of the device. Patients and methods: A case of migration of IUD through rectal wall is presented in a woman of 40 years old, who came to the emergency department with sudden pain and rectal bleeding. The physical examination aimed to the horizontal component of the IUD getting out through the anal canal and hosted by DRE the vertical component at right is palpable. This localization is verified by performing abdominal and pelvic CT. In this case, a colonoscopic removal of foreign body was made. Conclusions: In general, when a perforation is identified, the extraction of the device is recommended as soon as possible. Endoscopic techniques or surgery could be use for it depending on the location; so that each case must be individualized

Aortic Graft Mycotic Pseudoaneurysm as a Severe Complication After Multivisceral Transplantation: A Case Report.

BACKGROUND: Surgical complications in multivisceral transplantation (MVT) are frequent and always severe. Those related to technical issues are relevant as they have implications not only on the graft but also on patient survival. The aim of this study was to review our case-based data and experience with 5 MVT performed since December 2004. CASE REPORT: A 38 year-old woman presented with ultra-short bowel syndrome due to massive ischemia also affecting the celiac trunk. She also had moderate to severe hepatitis/steatosis with some degree of fibrosis on liver biopsy, due to long-term home parenteral nutrition (HPN). An MVT was carried out in September 2010 including the liver, stomach, pancreatoduodenal complex with the spleen, and small bowel. The postoperative course was complicated by a leak from the pyloromiotomy, requiring reoperation on postoperative day 13. She also had central line catheter infection and renal impairment, requiring renal replacement therapy, and was discharged on postoperative day 150. Fifteen days later she was hospitalized because of severe abdominal pain associated with an abdominal mass. Computed tomography showed an aortic donor graft pseudoaneurysm, so we decided to operate on the patient. A complete resection of the pseudoaneurysm using an interposed polytetrafluoroethylene graft was performed. Six months after the MVT, the patient died due to sepsis, despite a functional graft and complete digestive autonomy. CONCLUSIONS: Although this complication is rare, surgical complications in MVT are severe and may seriously impair graft and patient survival.

Histologic evaluation of organ preservation injury and correlation with cold ischemia time in 13 intestinal grafts.

Lesions produced in the graft mucosa due to harvesting, storage, and implantation must be graduated to assess the subsequent protocolized biopsy specimens. The aim is to identify type and intensity of graft mucosal lesions observed immediately after implantation. Congestion, hemorrhage, microthrombi, neutrophilic infiltrates, shortening of villi, epithelial detachment, erosion, and crypt loss were separately evaluated by two pathologists in mucosal biopsy specimens from 13 grafts. Each change was assessed as normal, mild, moderate, or severe and by splintering the summation of points a global score was designed. Cold ischemia time was registered. Correlation between the pathologists' evaluations and between final preservation injury degree and cold ischemia time was determined using the "index of correlation rho (ρ)" (Spearman's test). The same changes were assessed in 19 biopsy specimens from day 2 to day 6 (3.6 ± 1.1) to determine their evolution. Congestion was found in 7 biopsy specimens, microthrombi in 2, hemorrhage in 4, neutrophils in 6, villous atrophy in 8, epithelial detachment in 9, erosions in 2 and/or crypt loss in 2. The maximum degree of preservation injury was expressed as intense congestion and hemorrhage associated with epithelial detachment and villous atrophy. The global preservation score was grade 3 in 2 cases, grade 2 in 5, grade 1 in 2, and grade 0 in 4. There was positive correlation (ρ = 0.915) in the evaluation between pathologists (P < .01), total agreement in 9 biopsy specimens, and partial agreement (only 1 point disagreement) in 4. Mean cold ischemia time was 327 ± 101 min. (135-480). There was positive correlation (ρ = 0.694) between preservation score and cold ischemia time (P < .01). In the follow-up biopsy procedures, histological injury decreased by at least one grade in every case. Additionally, karyorrhexis was observed in 3 grafts and very occasional apoptosis in 2 others. This scale achieves good reproducibility and allows graduate preservation injury in intestinal transplantation.

Histologic evaluation of post-implantation immediate C4d deposition in 13 intestinal grafts: correlation with cell-based crossmatching, cold ischemia time, and preservation injury.

C4d deposits are predictive of humoral rejection in kidney and heart transplantation. The aim of this study was to identify C4d deposit patterns in intestinal mucosa of the grafts on biopsy specimens obtained immediately after implantation and to detect if it could be a valuable tool to predict humoral or acute rejection. A second objective was to search for a statistically significant relationship between positive C4d deposition and other collected variables. Thirteen immediately post-transplantation mucosal graft biopsy specimens, formalin fixed, underwent immunohistochemical stain for C4d deposits. Diffuse intense staining of capillary endothelium was considered positive and absent, focal or weak stains as negative. Preservation injury grade and cold ischemia times were registered for each case. Donor-specific preformed antibodies were detected by complement dependent cytotoxicity serologic technique (crossmatching). Another 19 endoscopic follow-up biopsy specimens from days 2 to 6 were also evaluated. Statistical studies were made using the index of correlation ρ (Spearman's test). Diffuse intense C4d deposits were observed in 2 grafts, focal and weak in 5, and completely negative in 6. The mean cold ischemia time was 327 ± 101 minutes. Two cases showed diffuse positive deposits, 1 had a positive crossmatch and the cold ischemia time was 360 minutes whereas the other had not preformed antibodies and its cold ischemia time was 475 minutes. Humoral or acute rejection was not observed in follow-up mucosal biopsy specimens. There was no statistically significant relationship between the C4d deposition, cold ischemia time, crossmatching results, and preservation injury degree. In conclusion, C4d deposition was not a helpful tool for diagnosis of humoral rejection and prediction of acute rejection during the early post-transplantation period.

Renal failure associated with intestinal transplantation: our experience in Spain.

BACKGROUND: Renal failure (RF) is a frequent complication in non-renal solid organ transplants. In the present study, we analyze our experience with intestinal transplants (ITx). METHODS: Between 2004 and 2012, we performed 21 ITx in 19 adult patients. Alemtuzumab was used as an induction agent followed by tacrolimus. Renal function was assessed before ITx and during the perioperative period. RESULTS: The main cause for transplants was non-resectable desmoids tumors (33.3%), followed by vascular thrombosis (19%) and others. Medical complications were frequent, especially infectious diseases, which were the most common (51%). Surgical complications were also frequent, but most of them (>50%) were mild but leading to a great number of re-operations and prolonged stays in hospital. Acute rejection is very frequent (66.6%) but mild in more than 70% of the cases. Finally, RF was very frequent (68.4%; 13/19 patients) and accounted for 15.6% of all medical complications. Causes were multiple. One patient is awaiting a kidney transplant, but no other patients need renal replacement therapy at the moment. Ileostomy closure was performed in 5 of 12 patients alive, showing improved renal function in 3 of them. CONCLUSIONS: RF is a problem in ITx and is always multifactorial. Increases in hospital stay, higher morbidity and is a cause for hospital readmission. Almost all patients had an impaired renal function when discharged. Immunosuppressants and ileostomy closure as soon as possible might prevent RF.

Porcine acellular dermal matrix for delayed abdominal wall closure after pediatric liver transplantation.

Children are one of the groups with the highest mortality rate on the waiting list for LT. Primary closure of the abdominal wall is often impossible in the pediatric population, due to a size mismatch between a large graft and a small recipient. We present a retrospective cohort study of six pediatric patients, who underwent delayed abdominal wall closure with a biological mesh after LT, and in whom early closure was impossible. A non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) Reconstructive Tissue Matrix; LifeCell Corp, Bridgewater, NJ, USA) was used in all of the cases of the series. After a mean follow-up of 26 months (21-32 months), all patients were asymptomatic, with a functional abdominal wall after physical examination. Non-cross-linked porcine-derived acellular dermal matrix (Strattice(™) ) is a good alternative for delayed abdominal wall closure after pediatric LT. Randomized controlled trials are necessary to determine the best moment and the best technique for abdominal wall closure.