Laparoscopic repair of acute traumatic diaphragmatic hernia with mesh reinforcement: A case report.

INTRODUCTION AND IMPORTANCE: Traumatic diaphragmatic injuries are rare and usually occur after thoracoabdominal trauma. Most patients will have other potentially life-threatening injuries. High index of suspicion is the most important attribute. Unfortunately, it is incorrectly diagnosed in up to 33% of cases. If left untreated, the onset of complications carries mortality rates between 25 and 80%. CASE PRESENTATION: We report a case of an acute diaphragmatic laceration in a 29-year-old male with thoracoabdominal trauma due to a road traffic accident. Physical examination revealed an absence of normal breath sounds in the left hemithorax. CT-scan confirmed a voluminous left diaphragmatic hernia with omental, gastric, and transverse colon content, so surgical intervention was advised. During laparoscopy, a 15 cm long and 5 cm wide diaphragmatic defect was identified. The hernia was reduced laparoscopically, and the defect repaired with interrupted non-absorbable sutures. As a reinforcement, a visceral contact prosthesis was placed. The patient had an uneventful recovery and after 12-month follow-up he has no evidence of recurrence. CLINICAL DISCUSSION: Diaphragmatic injuries do not close spontaneously. An abdominal approach is recommended as it allows for evaluation of the entire abdomen and treatment of any associated injury. Watertight closure with nonabsorbable suture and in case of large defects, the placement of a mesh on the peritoneal side of the diaphragm is recommended to reinforce the primary repair. CONCLUSION: Laparoscopic emergency surgery has proved to be effective and safe in selected patients with hemodynamic stability. Patients can expect the benefits of minimal invasive surgery with recurrence rate like the open approach.

Complex giant incisional hernia repair with intraperitoneal mesh: A case report.

INTRODUCTION AND IMPORTANCE: An incisional hernia is one of the most frequent complications after abdominal surgery, with an estimated incidence of 2-20% after midline laparotomy. They are often caused by poor wound healing. We present the case of a complex giant incisional hernia that was repaired by implanting an intraperitoneal mesh. CASE PRESENTATION: A 63-year-old man with obesity, hypertension, and multiple previous laparotomies, who developed a complex giant incisional hernia (xipho-pubic > 10 cm wide). An open technique repair was decided with the introduction of a large mesh (Parietex ™ Composite) in an intraperitoneal position, covering a 25 × 16 cm hernial ring. After two years, the patient continues to be followed due to a low-output distal enterocutaneous fistula. CLINICAL DISCUSSION: Currently, there is no technique or approach that has become a gold standard for ventral incisional hernia repair. The introduction of an intraperitoneal mesh with two surfaces by laparotomy is recommended when there are contraindications for laparoscopic surgery, for example in obese patients, and patients with multiple previous laparotomies. However, it has been reported to be a complex technique with an enterocutaneous fistula rate of 0.3-4%. CONCLUSION: The introduction of a composite mesh represents an alternative surgical technique for the repair of giant incisional hernias.

Neutrophil-to-lymphocyte ratio as a predictor of complicated acute diverticulitis: A retrospective cohort study.

INTRODUCTION: Currently, the debate on the usefulness of Neutrophil to Lymphocyte Ratio (NLR) as a predictor of complications in acute diverticulitis (AD) remains open, especially, the relation to the severity of the disease, the clinical impact, and the necessity of minimally invasive or emergency surgical procedures. On the other hand, its diagnostic efficacy has not been studied even in our field. The objective of the present study was to determine the utility and diagnostic precision of NLR in complicated acute diverticulitis (cAD). METHODS: Descriptive, retrospective cohort and analytical study. Patients older than 18 years with a diagnosis of AD were included, from 2013 to 2018. Demographic variables, days of hospitalization, leukocyte count, neutrophils, lymphocytes, ESR, CRP, and NLR were analyzed. The sensitivity and specificity for the diagnosis of cAD were determined using ROC curves. RESULTS: 325 patients were included. Of these 196 (60%) were men. The median age was 52 years. A total of 30 (9%) were categorized as cAD. The patients with cAD presented mean values in the leukocyte count (14.02 ± 4.49 × 109/l; p < 0.01), CRP (119.60 ± 87.67; p < 0.01) and NLR (7.61 ± 4.03; p < 0.01). An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD, with a sensitivity of 80%, a specificity of 64%, NPV of 96%, and PPV of 18%. CONCLUSION: NLR is a predictive marker of cAD, with a cut-off point of 4.2 being the best diagnostic approach.

Ileocecal intussusception as the initial presentation of endometriosis: case report.

Cecal endometriosis is a rare entity that can present as nonspecific acute abdominal pain and can be complicated by ileocolic intussusception, which is extremely infrequent. We present the case of a 33-year-old woman with no relevant pathological antecedents who consulted for abdominal pain for 5 days, associated with rebound tenderness and abdominal guarding on the right lower quadrant and a palpable mass during the physical examination. Computed tomography was realized and emergency surgery performed due to suspected ileocolic intussusception. The laparoscopic examination identified an ileocolic intussusception associated with a tumor. Conversion to open surgery was needed, and an oncological right hemicolectomy with ileotransverse anastomosis was carried out. Histopathological study reported ileocolic intussusception and a focus of cecal endometriosis. Currently, the patient does not have recurrences. Ileocolic intussusception secondary to deep endometriosis requires great diagnostic presumption in women of childbearing age with acute abdomen diagnosis.

[Congenital renal arteriovenous fistula: a rare cause of acute abdomen and a review of its literature]. / Fístula arteriovenosa renal congénita: una causa rara de abdomen agudo y revisión de la literatura.

Introduction: Congenital renal arteriovenous fistula is an abnormal connection between the arterial and venous system. Since the first case described in 1928 by Varela et al, no more than 200 cases have been published. Material and methods: A 45-year-old woman consulted for severe abdominal and low-back pain associated with arterial hypertension. The CT scan showed an infrarenal retroperitoneal lesion with invasion of neighboring structures. Results: During the abdominal exploration, a vascular-looking lesion of 60 x 34 x 41 mm was identified. It was associated with right nephrectomy. Discussion: The etiology of congenital fistulas remains unknown; it is believed that a congenital arterial aneurysm erodes into an adjacent vein and gradually increases its size. Other authors believe that the fistula exists since birth and gradually increases its size until it causes symptoms. Conclusion: Congenital arteriovenous fistulas are rare entities, representing less than 25% of all renal arteriovenous malformations.

Introducción: La fístula arteriovenosa renal congénita es una conexión anómala entre el sistema arterial y venoso. Desde el primer caso descrito en 1928 por Varela y cols, no más de 200 casos han sido publicados. Material y Método: Mujer de 45 años consultó por dolor abdominal y lumbar severo, asociado a hipertensión arterial. En tomografía computada se observó lesión retroperitoneal infrarrenal con invasión de estructuras vecinas. Resultados: En exploración abdominal se identificó lesión de aspecto vascular de 60 x 34 x 41 mm. Se asoció a nefrectomía derecha. Discusión: La etiología de las fístulas congénitas sigue siendo desconocida, se cree que un aneurisma arterial congénito erosiona hacia una vena adyacente y aumenta su tamaño lentamente. Otros autores creen que la fístula existe desde el nacimiento e incrementa progresivamente de tamaño hasta producir síntomas. Conclusión: Las fístulas arteriovenosas congénitas son entidades raras, representando menos del 25% del total de las malformaciones arteriovenosas renales.

Multiple intestinal perforations due to primary mediastinal B-cell lymphoma: A case with an infrequent extra-nodal presentation.

INTRODUCTION: Primary mediastinal B-cell lymphoma (PMBCL) is an uncommon subtype of non-Hodgkin lymphoma (2-3%), predominantly occurring in female young adults. Extrathoracic involvement is found in 10-20%. It can affect the kidneys, pancreas, stomach, adrenal glands, liver, and infrequently the central nervous system (6-9%). There is currently only one reported case of ileum dissemination with a single perforation. PRESENTATION OF CASE: A 51-year-old woman with a history of PMBCL, hospitalized by a superior vena cava syndrome. PET-CT showed numerous lesions in the small intestine, pancreas, adrenal glands, and left kidney. During chemotherapy she presented abdominal symptoms, requiring an emergency laparotomy. On examination, six perforation sites were found in the small intestine. The pathology report revealed lesions compatible with PMBCL spread. DISCUSSION: There are few case series with reports of dissemination in the gastrointestinal tract, with the main location in the stomach. Knowing the visceral location of the PMBCL would allow us to plan a strict follow-up during the first phases of chemotherapy treatment, as well as the early diagnosis of unexpected complications, such as intestinal perforation. CONCLUSION: The PMBCL is a rare entity. Visceral involvement should be suspected in these patients since intestinal perforation represents a complication with high morbidity and mortality. This is the first case reported with numerous intestinal locations and multiple post-chemotherapy perforations.