[Obscure gastrointestinal bleeding due to gastrointestinal stromal tumors]. / Hemorragia gastrointestinal de origen oscuro por tumores de estroma gastrointestinal.

BACKGROUND: The gastrointestinal stromal tumours (GIST) are the most common soft tissue sarcomas of the digestive tract. They are usually found in the stomach (60-70%) and small intestine (25-30%) and, less commonly, in the oesophagus, mesentery, colon, or rectum. The symptoms present at diagnosis are, gastrointestinal bleeding, abdominal pain, abdominal mass, or intestinal obstruction. The type of symptomatology will depend on the location and size of the tumour. The definitive diagnosis is histopathological, with 95% of the tumours being positive for CD117. CLINICAL CASES: This is an observational and descriptive study of 5cases of small intestinal GIST that presented with gastrointestinal bleeding as the main symptom. The period from the initial symptom to the diagnosis varied from 1 to 84 months. The endoscopy was inconclusive in all of the patients, and the diagnosis was made using computed tomography and angiography. Treatment included resection in all patients. The histopathological results are also described. CONCLUSION: GIST can have multiple clinical pictures and unusual symptoms, such as obscure gastrointestinal bleeding. The use of computed tomography and angiography has shown to be an important tool in the diagnosis with patients with small intestine GISTs.

Eventración diafragmática en el adulto. Reporte de un caso / Diaphragmatic eventration in adults. Case report

Resumen Introducción: El diafragma es un órgano fibromuscular cuya función fisiológica es otorgar la fuerza mecánica para la ventilación. Otra de las funciones del diafragma es dividir la cavidad torácica de la cavidad abdominal2. El diafragma se ve afectado rara vez por enfermedades. Entre las patologías primarias se encuentra la eventración diafragmática. Reporte de caso: Paciente del sexo femenino de 21 años de edad sin antecedentes de importancia quien presenta caída de su propia altura y trauma contuso en tórax. Se realiza radiografía como parte del estudio y se observa elevación del hemidiafragma izquierdo. El estudio se complementa con tomografía axial computada y se diagnostica eventración diafragmática. Ante los hallazgos, se plantea el procedimiento quirúrgico como terapia definitiva; sin embargo, la paciente no lo acepta, por lo que se ha mantenido en seguimiento por la consulta externa. Discusión: La eventración diafragmática es causada por debilidad de la parte muscular diafragmática. Se cree que es causada por la ausencia congénita o funcional de la musculatura diafragmática. El cuadro clínico generalmente es asintomático; en caso de existir sintomatología, ésta se relaciona a problemas respiratorios. El diagnóstico se corrobora con estudios radiológicos, de los cuales los más utilizados son la radiografía de tórax y la tomografía axial computada. El tratamiento puede ser conservador o quirúrgico. El pronóstico dependerá del grado de hipoplasia pulmonar y la de coexistencia de alguna otra alteración. Conclusión: La eventración diafragmática es rara vez diagnosticada en pacientes adultos asintomáticos. El manejo dependerá de la decisión del cirujano y del paciente.

Abstract Background: The diaphragm is a fibromuscular organ whose primary function is related to ventilation. It also serves as a barrier between pleural and abdominal cavities. This organ is rarely affected by pathologic entities, but eventration is among the primary diseases of this structure. Case Report: We present the case of a 21 year old female with no relevant personal history. She arrived to the emergency room with thoracic blunt trauma. Chest radiography is indicated, showing elevation of the left hemidiaphragm. This study was complemented with a computed tomography making a presumptive diagnosis of diaphragmatic eventration. As part of the treatment, we proposed surgical therapy but the patient refused and now she is under surveillance in her clinic. Discussion: Diaphragmatic eventration is caused by the weakness of the muscular part of the organ. It is thought that is caused by functional or congenital absence of the diaphragmatic musculature. The clinical presentation is variable but, in most of the cases, the patients are asymptomatic. The diagnosis is made by radiologic studies such as chest plains and computed tomography. Treatment could be conservative or surgical. The prognosis will depend on the degree of pulmonary hypoplasia and the coexistence of other malformations. Conclusion: Diaphragmatic eventration is rarely diagnosed in adults and the treatment will depend on the surgeon´s and the patient´s joined decision.

[Choledochal cyst during pregnancy. Report of 3 cases and a literature review]. / Quiste de colédoco y embarazo. Reporte de 3 casos y revisión de la bibliografía.

BACKGROUND: Choledochal cysts are rare. They usually present during childhood in women, but it can also be seen during pregnancy. Clinical signs and symptoms are obscured during this time, thus it can complicate the diagnosis and represent a life threatening complication for both the mother and the child. OBJECTIVE: To communicate the case of 3 pregnant patients with choledochal cyst. CLINICAL CASES: Three pregnant women in which choledochal cyst were diagnosed. Two developed signs of cholangitis. The first one underwent a hepatic-jejunostomy, but had an abortion and died on postoperative day 10. The second one had a preterm caesarean operation due to foetal distress and underwent a hepatic-jejunostomy 4 weeks later; during her recovery she had a gastric perforation and died of septic complications. The third one did not develop cholangitis or jaundice. She had an uneventful pregnancy and had a hepatic-jejunostomy 4 weeks later with good results. CONCLUSIONS: Management of choledochal cysts during pregnancy is related to the presence of cholangitis. When they do not respond to medical treatment, decompression of the biliary tree is indicated. Definitive treatment should be performed after resolution of the pregnancy.

[Experience of the surgical management of the esophageal achalasia in a tertiary care hospital]. / Experiencia del manejo quirúrgico de la acalasia esofágica en un hospital de alta especialidad.

INTRODUCTION: Achalasia is a primary esophageal motor disorder. The most common symptoms are: dysphagia, chest pain, reflux and weight loss. The esophageal manometry is the standard for diagnosis. The aim of this paper is to determine the effectiveness of the surgical management in patients with achalasia in a tertiary care hospital. METHODS: A case series consisting of achalasia patients, treated surgically between January and December of 2011. Clinical charts were reviewed to obtain data and registries of the type of surgical procedure, morbidity and mortality. RESULTS: Fourteen patients were identified, with an average age of 49.1 years. The most common symptoms were: dysphagia, vomiting, weight loss and pyrosis. Eight open approaches were performed and six by laparoscopy, with an average length of cardiomyotomy of 9.4 cm. Eleven patients received an antireflux procedure. The effectiveness of procedures performed was 85.7 %. CONCLUSIONS: Surgical management offered at this tertiary care hospital does not differ from that reported in other case series, giving effectiveness and safety for patients with achalasia.

Introducción: la acalasia es un trastorno motor primario del esófago. La sintomatología más frecuente es la disfagia, dolor torácico, reflujo y pérdida de peso. La manometría esofágica es el estándar para su diagnóstico. El objetivo de este trabajo fue determinar la eficacia del manejo quirúrgico de los pacientes con acalasia en nuestro centro hospitalario. Métodos: se realizó un estudio de serie de casos en el que se incluyeron pacientes con acalasia tratados de manera quirúrgica entre enero y diciembre de 2011. Se revisaron los expedientes para obtener los datos y registros del tipo de procedimiento quirúrgico realizado, morbilidad y mortalidad. Resultados: se incluyeron 14 pacientes con edad promedio de 49.1 años. Los síntomas predominantes fueron: disfagia, vómito, pérdida de peso y pirosis. Se realizaron ocho abordajes abiertos y seis laparoscópicos, con una longitud media de cardiomiotomía de 9.4 cm. Once pacientes recibieron un procedimiento antirreflujo concomitante. La efectividad de los procedimientos realizados fue del 85.7 %. Conclusiones: el manejo quirúrgico ofrecido en nuestro centro no difiere de lo reportado en otras series de caso, lo que otorga efectividad y seguridad a los pacientes tratados con acalasia.

[Hepatic artery pseudoaneurysm: report of two cases]. / Pseudoaneurisma de arteria hepática: reporte de dos casos.

BACKGROUND: Hepatic pseudoaneurysm is rare and potentially fatal. It occurs as a consequence of injury to the vascular wall, erosion diathermy through clips, biliary leakage and secondary infection. The main symptom is intra-abdominal bleeding. OBJECTIVE: To communicate the case of two patients with hepatic pseudoaneurysm. CLINICAL CASES: Case 1: We present a 43 year-old male with a history of grade IV liver injury due to blunt abdominal trauma and managed surgically. Case 2: A 67 year-old man with bile duct injury after laparoscopic cholecystectomy. Both patients presented with biliary leakage, abdominal sepsis and late intra-abdominal bleeding. Tomographic studies showed the lesion. Superselective embolization was performed proximal and distal to the lesion with good results. During follow-up, none of them showed signs of recurrent bleeding. CONCLUSIONS: Hepatic artery pseudoaneurysm is rare and usually secondary to bile duct injury associated with vascular injury after cholecystectomy or liver trauma. Arteriography with embolization is the best diagnostic and therapeutic procedure. Surgery is indicated for hemodynamically unstable patients, embolization failure or rebleeding. Early diagnosis reduces morbidity and mortality of this complication.

Antecedentes: el pseudoaneurisma de la arteria hepática es una alteración rara y potencialmente mortal. El daño directo a la pared vascular, la erosión diatérmica a través de los clips, la fuga biliar y la infección secundaria son los factores precipitantes. La principal manifestación es la hemorragia intraabdominal. Objetivo: describir dos casos de pseudoaneurisma de la arteria hepática. Casos clínicos: Caso 1: paciente masculino de 43 años de edad con antecedentes de lesión hepática grado IV por traumatismo cerrado de abdomen tratado quirúrgicamente. Caso 2: paciente masculino de 67 años de edad con lesión en la vía biliar por colecistectomía laparoscópica. Ambos ingresaron con fuga biliar y sepsis abdominal. Durante la evolución posoperatoria sufrieron hemorragia intraabdominal. Por angiotomografía se observó un pseudoaneurisma de la arteria hepática en los dos pacientes. Se les realizó embolización superselectiva proximal y distal a la lesión, con buenos resultados. Durante su seguimiento no hubo nuevos episodios de hemorragia. Conclusiones: el pseudoaneurisma de la arteria hepática es muy raro y, por lo general, secundario a una lesión de la vía biliar, con lesión vascular concomitante por colecistectomía o traumatismo hepático. La angiotomografía es diagnóstica y la arteriografía con embolización es el recurso diagnóstico y terapéutico más recomendado. La intervención quirúrgica está indicada ante inestabilidad hemodinámica, embolización fallida y resangrado. El diagnóstico temprano reduce la morbilidad y mortalidad de esta complicación.

[Acute pancreatitis and afferent loop syndrome. Case report]. / Pancreatitis aguda y síndrome de asa aferente. Reporte de caso.

BACKGROUND: The afferent syndrome loop is a mechanic obstruction of the afferent limb before a Billroth II or Roux-Y reconstruction, secondary in most of case to distal or subtotal gastrectomy. Clinical case: Male 76 years old, with antecedent of cholecystectomy, gastric adenocarcinoma six years ago, with subtotal gastrectomy and Roux-Y reconstruction. Beginning a several abdominal pain, nausea and vomiting, abdominal distension, without peritoneal irritation sings. Amylase 1246 U/L, lipase 3381 U/L. Computed Tomography with thickness wall and dilatation of afferent loop, pancreas with diffuse enlargement diagnostic of acute pancreatitis secondary an afferent loop syndrome. CONCLUSION: The afferent loop syndrome is presented in 0.3%-1% in all cases with Billroth II reconstruction, with a mortality of up to 57%, the obstruction lead accumulation of bile, pancreatic and intestinal secretions, increasing the pressure and resulting in afferent limb, bile conduct and Wirsung conduct dilatation, triggering an inflammatory response that culminates in pancreatic inflammation. The severity of the presentation is related to the degree and duration of the blockage.

Antecedentes: el síndrome de asa aferente se caracteriza por la obstrucción mecánica del asa aferente luego de la reconstrucción tipo Billroth II o en Y de Roux, en la mayoría de los casos secundaria a gastrectomía distal o subtotal. Caso clínico: paciente masculino de 76 años de edad, con antecedentes de: colecistectomía, adenocarcinoma gástrico seis años previos, gastrectomía subtotal y reconstrucción en Y de Roux. Inició con dolor abdominal, náusea y vómito; abdomen distendido, sin datos de irritación peritoneal. Amilasa 1246 U/L, lipasa 3381 U/L. La tomografía computada abdominal mostró dilatación y engrosamiento de la pared del asa aferente y el páncreas con incremento de tamaño. Se le diagnosticó pancreatitis aguda, originada por síndrome de asa aferente. Conclusiones: el síndrome de asa aferente aparece en 0.3 a 1% de los casos de pacientes con reconstrucción Billroth II, a consecuencia de la obstrucción mecánica del asa aferente, con mortalidad incluso de 57%. La obstrucción del intestino aferente por acumulación de secreción biliar, pancreática e intestinal incrementa la presión, que resulta en dilatación del asa aferente de la vía biliar y del conducto de Wirsung, lo que desencadena una respuesta inflamatoria que finaliza en un cuadro de pancreatitis. Su manifestación severa se relaciona con el grado y duración de la obstrucción.

[Biliary ileus: 10-year experience. Case series]. / Íleo biliar. Experiencia de 10 años. Serie de casos.

BACKGROUND: Biliary ileus is present in 0.06% of patients with gallstones as an outcome of a cholecystoenteric fistula, most frequently presenting as an intestinal obstruction. It is a clinic entity occasionally diagnosed, which translates into a significant margin of complications and mortality ranging from 12 to 27%. Our objective is to report the experience in the treatment of this pathology in a tertiary care hospital. METHODS: We carried out a retrospective study in patients with a diagnosis of biliary ileus during a 10-year period. RESULTS: thirteen patients were included in the study, nine males (69%) and four females (31%) with a mean age of 57 years. All patients had intestinal occlusion symptoms. Preoperative diagnosis was achieved in three patients (23%). The most common surgery was intestinal resection with anastomosis (54%). One patient from the study group died (8%). Hospitalization length was a mean of 15 days and average follow-up was 11 months. CONCLUSIONS: Bilary ileus is a pathology of patients of advanced age and must be suspected when symptoms of occlusion are present, regardless of gender. Early diagnosis can mean earlier intervention and potentially less traumatic surgery. Treatment is focused on urgent laparotomy and resolution of the intestinal occlusion, leaving management of the biliary fistula to only selected cases.

[Cystic neoplasm of the pancreas: a ten years experience]. / Tumores quísticos de páncreas. Informe de 10 años.

BACKGROUND: Pancreatic cystic lesions (PCL) are identified in 1 % of patients who undergo abdominal computed tomography scans, because it is difficult to discriminate clinically between benign and malignant PCL. The PCL must be distinguished from inflammatory pseudocysts, which can have a similar radiographic appearance. The aim of this study was to review the incidence of PCL during 10 years. METHODS: Nineteen consecutive patients who underwent surgical resection of a cystic lesion of the pancreas during a 10-year period were reviewed. RESULTS: From 1998, 434 patients underwent to pancreatic surgery, 103 (25.75%) resulted with neoplasm of the pancreas and a PCL was diagnosed in 19 of them (18.44%). They were more common in women (n=15, 79%). The pathologic diagnosis was mucinous cystadenoma (n=6, 31.5%) followed by serous cystadenoma and solid cystic papilar tumor (n=4, 21%). Mucinous cystadenocarcinoma was diagnosed in a 77 year-old man and a serous cystadenocarcinoma was diagnosed in a 53 years-old woman; cystic degeneration of two insulinomas were diagnosed in a 71 year-old woman and a 32 year-old man (5.26%). CONCLUSIONS: PCLs represent a spectrum of associated diseases. The incidence of serous cystadenoma is lower in our experience.

[Splenectomy incidence in a specialized care hospital]. / Incidencia de esplenectomías en un hospital de tercer nivel de atención.

BACKGROUND: splenectomy has been elected surgical procedure for multiple hematologic diseases, specially for Idiopathic Thrombocytopenic Purpura. The aim of this study was to compare the incidence of splenectomies in two different periods of time and to show decrease tendency during the most recent years. METHODS: it was a retrospectively reviewed study from medical records of patients who underwent splenectomy at the Hospital de Especialidades Siglo XXI, between 1986 to 1990 and 1995 to 1999. RESULTS: during the first period of time, the incidence of splenectomies for hospital admissions was 0.52%, and in the second 0.19%. CONCLUSIONS: the incidence of splenectomies performed at the Hospital de Especialidades Siglo XXI decreased in the second period of time, probably because there are new available treatments for hematologic diseases.

[Bariatric surgery for pseudotumor cerebri. Case report]. / Tratamiento del pseudotumor cerebri con cirugia bariátrica. Reporte de un caso.

INTRODUCTION: We report here a case of a patient with pseudotumor cerebri (PTC) associated with morbid obesity. PTC, also called benign intracranial hypertension, is a known complication of morbid obesity with resolution by reduction of obesity. CLINICAL CASE: A 42-year-old female with morbid obesity and secondary PTC underwent a modified jejunocolonostomy. RESULTS: The patient has lost 43% of excess body weight and the intracranial pressure is normal. CONCLUSIONS: PTC is a benign pathology, and the cause may be morbid obesity. Bariatric surgery is useful in the management of these patients for the resolution of this disease.

[Abdominal pseudocyst in a patient with ventriculoperitoneal shunt. A case report]. / Pseudoquiste abdominal en paciente con derivación ventriculoperitoneal. Reporte de un caso.

Since 1905, the abdominal cavity has been used for absorption of cerebrospinal fluid in patients with hydrocephalus. Among complications in its use is formation of abdominal pseudocysts. We describe the case of a patient with hydrocephalus who developed an abdominal pseudocyst. The main complaint of the patient was abdominal pain and fever. During physical examination, a 15-cm abdominal tumor was detected. The patient underwent abdominal surgery for excision of the pseudocyst and peritoneal shunt was relocated to right atrium. Recovery was uneventful. Incidence of abdominal pseudocyst ranges from 1-4.5%. Principal symptoms are related with intracranial hypertension. The patient usually requires surgical exploration to resolve the illness, and in presence of infection the shunt should be changed.

[Frantz-Gruber tumor: a case report]. / Tumor de Frantz-Gruber: reporte de un caso.

OBJECTIVE: The objective of this report is to describe the existence of a rare tumor that must be taken into consideration when studying the diagnosis of pancreatic tumors. CASE REPORT: A 20-year-old female with abdominal pain as an only manifestation was seen. The diagnosis of a pancreatic head and body tumor was made. During surgery, we found a tumor in the head and body of the pancreas that measured approximately 10 x 7 cm; histopathologic study revealed a solid and cystic papillary epithelial neoplasm of the pancreas. DISCUSSION: Frantz-Gruber tumor is a rare pancreatic tumor suspected during the evaluation of a young female with abdominal pain and confirmed during surgery. It is important to consider the existence of this tumor in the evaluation of patients with these characteristics; even if the tumor's biological behavior is benign Frantz-Gruber tumor is considered a low-grade malignant tumor

[Sclerosing encapsulated peritonitis. Diagnostic and therapeutic challenge for the general surgeon]. / Peritonitis esclerosante encapsulante. Reto diagnóstico y terapéutico para el cirujano general.

Intestinal obstruction is one of the most frequently abdominal problems that concern general surgeons. One of the infrequent causes of mechanical obstruction is sclerosing encapsulating peritonitis (SEP); this entity causes intense fibrosis of the components in the peritoneal layer, resulting in adhesion of abdominal organs. SEP can be primary or secondary; both are a type of peritoneal fibrosclerosis that causes intestinal obstruction with difficult resolution and a great number of complications. In terms of frequency and etiology, there are few data, and the problem is considerated a multifactorial disease with association to neoplasms, toxics, drugs, and idiopathic form. This article presents three cases of sclerosing encapsulating peritonitis and the possible factors that play an important role in the development of this infrequent entity.

Morbilidad y mortalidad en cirugía por cáncer gástrico / Morbidity and mortality in gastric cancer surgery

Antecedentes. La cirugía constituye la única terapia efectiva en la cura del cáncer gástrico. Se han señalado diversos factores que pueden influir en la morbilidad y la mortalidad de los procedimientos quirúrgicos en la cirugía de cáncer gástrico. Objetivo. Determinar la morbilidad y mortalidad perioperatoria en cirugía por cáncer gástrico y establecer los factores de riesgo en las mismas. Método. Se revisaron 147 expedientes de pacientes operados con diagnóstico de adenocarcinoma gástrico. Se reportó la morbilidad posquirúrgica y la mortalidad perioperatoria. Se analizaron los factores demográficos, la evaluación física preoperatoria, los parámetros bioquímicos, la técnica quirúrgica y la biología tumoral, como factores de riesgo para morbilidad y mortalidad perioperatoria. Resultados. Durante un periodo de siete años se operaron 120 pacientes por cáncer gástrico. La media de edad fue de 58.07 años. El procedimiento quirúrgico más utilizado fue la gastrectomía subtotal en 42.5 por ciento (n=51). La morbilidad fue de 26.66 por ciento (n=32). La complicación no quirúrgica más común fue la insuficiencia renal (n=6,14.63 por ciento) y la complicación quirúrgica más frecuente fue la infección de la herida (n=7,17.07 por ciento). La mortalidad fue de 13.33 por ciento (n=16). Los factores de riesgo estadísticamente significativos para morbilidad fueron: la edad, la valoración ECOG, el índice de riesgo cardiaco Goldman y la cuenta total de linfocitos. Los factores de riesgo estadísticamente significativos para mortalidad fueron el índice de riesgo cardiaco Goldman, la albúmina sérica, la creatinina sérica y la cuenta total de linfocitos. Conclusión. La morbilidad y mortalidad en cirugía por cáncer gástrico está influenciada por las condiciones preoperatorias de los pacientes