Type II intrapancreatic choledochal malignant cyst in adults: duodenopancreatectomy.

A 62-year-old female patient was admitted for abdominal pain and vomiting. Imaging tests revealed a solid-cystic lesion at the head of the pancreas communicating with the distal bile duct. A Todani type II choledochal cyst was diagnosed with neoplastic degeneration after cytological diagnosis with endoscopic ultrasound-guided puncture. The patient was treated with a cephalic duodenopancreatectomy with curative intention.

Bariatric surgery, a risk factor for rhabdomyolysis

La rabdomiolisis tras cirugía bariatrica es una complicación rara pero posible. Presentamos un caso de rabdomiolisis y fallo renal agudo tras by-pass gástrico laparoscópico en paciente con obesidad mórbida. Su conocimiento puede ayudar a predecir y manejar esta complicación infradiagnosticada cuyo diagnostico precoz mejora el tratamiento de estos pacientes y previene las complicaciones posteriores (AU)

Rhabdomyolysis has been increasingly recognized as a complication of bariatric surgery. We report a case of this complication and its consequences, in a patient who had undergone bariatric surgery, with a very high creatine kinase (CK) concentration, and whose renal function failed. Obesity causes a range of effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage this underestimated complication in this population in which early diagnosis can alter the outcome (AU)

Bariatric surgery, a risk factor for rhabdomyolysis.

Rhabdomyolysis has been increasingly recognized as a complication of bariatric surgery. We report a case of this complication and its consequences, in a patient who had undergone bariatric surgery, with a very high creatine kinase (CK) concentration, and whose renal function failed. Obesity causes a range of effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage this underestimated complication in this population in which early diagnosis can alter the outcome.

Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients.

OBJECTIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass (LGBP), but its frequency is about 15% according to bibliography. Our aim is to present our experience after 62 LGBP. PATIENTS AND METHOD: From January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass (Wittgrove's technique). The gastrojejunal anastomosis is performed with auto suture material type CEAA No 21 termino-lateral (ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy, perform the anastomosis in the same way. Monitoring has a range of 3-35 months, conducted in 61 patients because one patient died of pulmonary thromboembolism in the immediate postoperative period after reoperation, after two weeks of gastric bypass, by necrosis of a small fragment of the remnant gastric. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation (recommending dilate the anastomosis to a maximum 1.5 cm). RESULTS: Five cases (8.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and in 1 case by endoscopy. Two patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion (circumferentially sclerosis within 48 hours of surgery and sclerosis of bleeding points). All cases were resolved by endoscopic dilatation. At follow-up has not been detected re-stricture. CONCLUSION: Clinically, gastrojejunal stricture results in a progressive oral intolerance, revealing stenosis between 1 and 3 months postoperatively. The situations of sclerosis of the bleeding lesions favor, especially in cases of extensive sclerosis. In cases of suspected barium transit offers us a high diagnostic yield. Endoscopic dilatation resolved, so far, all cases.

Adult intussusception - 14 case reports and their outcomes.

AIMS: To analyze diagnostic and therapeutic options depending on the clinical symptoms, location, and lesions associated with intussusception, together with their follow-up and complications. PATIENTS AND METHODS: Patients admitted to the Morales Meseguer General University Hospital (Murcia) between January 1995 and January 2009, and diagnosed with intestinal invagination. Data related to demographic and clinical features, complementary explorations, presumptive diagnosis, treatment, follow-up, and complications were collected. RESULTS: There were 14 patients (7 males and 7 females; mean age: 41.9 years-range: 17-77) who presented with abdominal pain. The most reliable diagnostic technique was computed tomography (8 diagnoses from 10 CT scans). A preoperative diagnosis was established in 12 cases. Invaginations were ileocolic in 8 cases (the most common), enteric in 5, and colocolic in 2 (coexistence of 2 lesions in one patient). The etiology of these intussusceptions was idiopathic or secondary to a lesion acting as the lead point for invagination. Depending on the nature of this lead point, the cause of the enteric intussusceptions was benign in 3 cases and malignant in 2. Ileocolic invaginations were divided equally (4 benign and 4 malignant), and colocolic lesions were benign (2 cases). Conservative treatment was implemented for 4 patients and surgery for 10 (7 in emergency). Five right hemicolectomies, 3 small-bowel resections, 2 left hemicolectomies, and 1 ileocecal resection were performed. Surgical complications: 3 minor and 1 major (with malignant etiology and subsequent death). The lesion disappeared after 3 days to 6 weeks in patients with conservative management. Mean follow-up was 28.25 months (range: 5-72 months). CONCLUSIONS: A suitable imaging technique, preferably CT, is important for the diagnosis of intussusception. Surgery is usually necessary but we favor conservative treatment in selected cases.

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Nuestra experiencia con 62 pacientes / Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients

Objetivo: la estenosis de la anastomosis gastroyeyunal representauna complicación nada desdeñable en la cirugía bariátricapor laparoscopia, llegándose, en algunas series, a alcanzar el15%. Presentamos nuestra casuística en una serie de 62 casosconsecutivos y el manejo realizado.Pacientes y método: desde enero-2004 a septiembre-2006hemos realizado de manera consecutiva 62 bypass gástricos porlaparoscopia según técnica de Wittgrove modificada. La anastomosisgastroyeyunal se realiza con material de autosutura tipoCEAA nº 21 término-lateral (ILS; Ethicon) y después de comprobarla estanqueidad anastomótica se dan dos puntos de válvulatipo Hoffmeister a cada lado de la anastomosis. En 4 casos(6,45%) se reconvirtió a laparotomía, realizándose la anastomosisde la misma manera. El seguimiento tiene un rango de 3-35 meses,realizado en 61 enfermos, pues un paciente falleció por tromboembolismopulmonar en el postoperatorio inmediato tras reintervención,a las dos semanas del bypass gástrico, por necrosis deun pequeño fragmento del remanente gástrico.En todos los pacientes con intolerancia persistente a la alimentaciónse realizó tránsito baritado y/o gastroscopia. Cuando seevidenció estenosis gastroyeyunal se procedió a dilatación neumáticaendoscópica (recomendando dilatar la anastomosis hastacomo máximo 1,5 cm).Resultados: en 5 casos (8,1%) se desarrolló una estenosisgastroyeyunal, en 4 de estos casos el diagnóstico inicial fue portránsito baritado y en 1 caso por endoscopia. Dos pacientes teníanantecedentes de HDA que precisaron esclerosis endoscópicade la lesión sangrante (esclerosis circunferencial a las 48 horas dela cirugía y esclerosis de puntos sangrantes). Todos los casos seresolvieron mediante dilatación endoscópica, precisando en doscasos dos sesiones de dilatación y el resto una. En el seguimientono se han detectado re-estenosis...(AU)

Objective: gastrojejunal stricture (GYS), not only is a commoncomplication after laparoscopic gastric bypass (LGBP), butits frequency is about 15% according to bibliography. Our aim isto present our experience after 62 LGBP.Patients and method: from January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass(Wittgrove´s technique). The gastrojejunal anastomosis is performedwith auto suture material type CEAA No 21 termino-lateral(ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy,perform the anastomosis in the same way. Monitoring has arange of 3-35 months, conducted in 61 patients because one patientdied of pulmonary thromboembolism in the immediate postoperativeperiod after reoperation, after two weeks of gastric bypass,by necrosis of a small fragment of the remnant gastric. In allpatients with persistent feeding intolerance were performed bariumtransit and/or gastroscopy. When gastrojejunal strictureshowed proceeded to endoscopic pneumatic dilation (recommendingdilate the anastomosis to a maximum 1.5 cm).Results: five cases (8.1%) developed a gastrojejunal stricture,in 4 of these cases the initial diagnosis was made by barium transitand in 1 case by endoscopy. Two patients had a history of digestivebleeding that required endoscopic sclerosis of the bleeding lesion(circumferentially sclerosis within 48 hours of surgery andsclerosis of bleeding points). All cases were resolved by endoscopicdilatation. At follow-up has not been detected re-stricture.Conclusion: Clinically, gastrojejunal stricture results in a progressiveoral intolerance, revealing stenosis between 1 and 3months postoperatively. The situations of sclerosis of the bleedinglesions favor, especially in cases of extensive sclerosis. In cases ofsuspected barium transit offers us a high diagnostic yield. Endoscopicdilatation resolved, so far, all cases(AU)

Intususcepción en el adulto. Revisión de 14 casos y su seguimiento / Adult intussusception - 14 case reports and their outcomes

Objetivos: analizar las opciones terapéuticas en función de laclínica, localización y lesión asociada a la intususcepción, asícomo, su seguimiento y complicaciones.Pacientes y métodos: pacientes ingresados en el HGU MoralesMeseguer (Murcia) desde enero de 1995 hasta enero 2009,con diagnóstico de invaginación intestinal. Se recogieron datosdemográficos, clínicos, exploraciones complementarias, diagnósticopresuntivo, tratamiento, seguimiento y complicaciones.Resultados: 14 pacientes (edad media 41,9 años, rango: 17-77), 7 varones y 7 mujeres, que debutaron principalmente condolor abdominal. La exploración más fiable en el diagnóstico fuela tomografía computerizada, TC (8 diagnósticos, de 10 exploraciones).El diagnóstico preoperatorio se obtuvo en 12 casos, encontrando,invaginaciones ileocólicas en 8 casos (las más frecuentes),entéricas en 5 casos y colocólicas en 2, teniendo en cuentaque son 14 los pacientes y 15 las lesiones debido a la coexistenciade 2 invaginaciones en un mismo sujeto. La etiología de las intususcepcioneses idiopática o secundaria a una lesión que hace de cabeza de invaginación. Según la naturaleza de dichas lesiones lacausa de intususcepciones entéricas fue benigna en 3 casos y malignaen 2. De las ileocólicas, se repartieron equitativamente (4benignas y 4 malignas); y de las colocólicas, sus lesiones fueronbenignas (2 casos). Se realizó tratamiento conservador en 4 pacientesy quirúrgico en 10 (7 urgente). Con 5 hemicolectomías derechas,3 resecciones de intestino delgado, 2 hemicolectomías izquierdasy una resección ileocecal. Las complicacionesquirúrgicas: 3 menores y 1 mayor (de etiología maligna y consecuenteexitus). En los pacientes con manejo conservador desaparecióla lesión entre 3 días y 6 semanas. Se siguieron durante28,25 meses de media (rango 5-72 meses)...(AU)

Aims: to analyze diagnostic and therapeutic options dependingon the clinical symptoms, location, and lesions associated withintussusception, together with their follow-up and complications.Patients and methods: patients admitted to the MoralesMeseguer General University Hospital (Murcia) between January1995 and January 2009, and diagnosed with intestinal invagination.Data related to demographic and clinical features, complementaryexplorations, presumptive diagnosis, treatment, followup,and complications were collected.Results: there were 14 patients (7 males and 7 females; meanage: 41.9 years-range: 17-77) who presented with abdominal pain.The most reliable diagnostic technique was computed tomography(8 diagnoses from 10 CT scans). A preoperative diagnosis was establishedin 12 cases. Invaginations were ileocolic in 8 cases (themost common), enteric in 5, and colocolic in 2 (coexistence of 2 lesionsin one patient). The etiology of these intussusceptions was idiopathicor secondary to a lesion acting as the lead point for invagination.Depending on the nature of this lead point, the cause of theenteric intussusceptions was benign in 3 cases and malignant in 2.Ileocolic invaginations were divided equally (4 benign and 4 malignant),and colocolic lesions were benign (2 cases). Conservativetreatment was implemented for 4 patients and surgery for 10 (7 inemergency). Five right hemicolectomies, 3 small-bowel resections,2 left hemicolectomies, and 1 ileocecal resection were performed.Surgical complications: 3 minor and 1 major (with malignant etiologyand subsequent death). The lesion disappeared after 3 days to6 weeks in patients with conservative management. Mean follow-upwas 28.25 months (range: 5-72 months).Conclusions: a suitable imaging technique, preferably CT, isimportant for the diagnosis of intussusception. Surgery is usuallynecessary but we favor conservative treatment in selected cases(AU)

Diagnóstico, tratamiento y seguimiento a largo plazo de los tumores del estroma gástrico / Diagnosis, therapy and follow-up gastrointestinal stromal tumors

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Mortality following laparoscopic ventral hernia repair: lessons from 90 consecutive cases and bibliographical analysis.

The popularity of laparoscopic repair of ventral hernias is increasing due to the apparent advantages of the procedure, but this approach is still a controversial technique. The aim of our study was to evaluate the mortality rate of laparoscopic ventral hernia repair and analyse the literature. The authors performed a prospective study in 90 patients with ventral hernia who were treated by laparoscopic repair. Clinical parameters and intra- and postoperative complications were evaluated. A case of mortality was reported due to a nonrecognised bowel injury. The mean follow-up (100%) was 42 months (range: 1-5 years). A bibliographical analysis was carried out (MEDLINE). Four bowel injuries were presented (4.4%): three recognised, which required conversion (two treated with minilaparotomy and completed afterwards by laparoscopy, and one by laparotomy); and one nonrecognised, which was re-operated on but evolved to sepsis and multiorgan failure and resulted in death in 48 h (1.1%). Four further mortality rates have been documented in the literature (0.6%, 1.1%, 3.1%, and 3.4% of their series). Bowel injury and mortality show a statistically significant tendency to decrease with the number of operations ( P<0.05). In conclusion, in our study the risk of mortality with laparoscopic ventral hernia repair has been higher than 1%, which must be made known. It is a risk that depends on the surgeon's experience but which does not seem to be predictable.

Hombre de 48 años con dolor abdominal recurrente de 8 meses de evolución, anemia y pérdida de peso / A 48 year old man with recurrent abdominal pain of months of evolution, anemia and low weight

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Intestinal invagination in adults: preoperative diagnosis and management.

BACKGROUND AND AIMS: Intestinal invagination in adults is an uncommon but potentially serious condition that is usually diagnosed during surgery by the presence of a mechanical obstructive syndrome. We report a series of adults with intestinal invagination and discuss preoperative diagnosis and surgical procedures. PATIENTS AND METHODS: We analyzed the files of all the seven patients aged over 18 years with a postoperative diagnosis of intestinal invagination and treated at our center between 1996 and 2000. RESULTS: Preoperative causal diagnosis was established in six cases by ultrasonography and computed tomography. All the patients received surgery, three as emergency and four programmed. The lesions causing the invagination were: three benign (Meckel's diverticulum, inflammatory pseudotumor, fibroid polyp) and one malignant (degenerative villous adenoma polyp) located in the terminal ileum, two malignant lesions in the cecum (both adenocarcinomas over a polyp), and in the remaining case a double lymphoma of the jejunum and ileum. The intussusceptions were ileoileal in three cases and ileocolic in four. We performed intestinal resection in six cases and one excision of Meckel's diverticulum. CONCLUSION: Preoperative diagnosis of intussusception was possible in most cases. Sonography and computed tomography proved the most effective and useful preoperative diagnostic methods. In adults colonic invagination is almost always malignant while small bowel is almost always benign. Invagination in adults must be clarified by surgery, and intestinal resection is the procedure of choice.