Leiomiosarcoma de vena cava inferior, reconstrucción mediante interposición de prótesis y anticoagulación

El leiomiosarcoma primario de vena cava es una neoplasia poco frecuente originada a nivel de las células musculares lisas de la túnica media. Representa el 2% de todos los leiomiosarcomas y el 60% de los tumores de vena cava. Presentamos el caso clínico de una paciente de 64 años que consulta por dolor lumbar derecho. La tomografía computada evidencia una gran masa retroperitoneal que engloba la vena cava inferior y contacta con el riñón derecho; el estudio histopatológico de la biopsia certifica un leiomiosarcoma. Se realiza tratamiento quirúrgico mediante resección tumoral con vena cava inferior e interposición de prótesis sintética y nefrectomía derecha. El estudio anatomopatológico de la pieza certifica un leiomiosarcoma de alto grado sin compromiso de la cápsula renal con bordes de resección libres. La resección radical con márgenes negativos actualmente ofrece la mejor tasa de supervivencia. Aún se encuentra en discusión la indicación de la anticoagulación en pacientes con colocación de prótesis.

Primary leiomyosarcoma of the vena cava is a very rare neoplasm that originates from the smooth muscle cells of the tunica media. It represents 2% of all the leiomyosarcomas and 60% of the vena cava tumors. We report a case of 64-year-old patient consulting for a lower right back pain. The computed tomography shows a large retroperitoneal mass which encompasses the inferior vena cava and involves of right kidney. The surgical treatment of tumor resection is performed with right nephrectomy and interposition of Dacron prosthesis. The anatomopathological study shows a high-grade leiomyosarcoma, not compromising the renal capsule, with resection free. Radical resection with negative margins currently offers the best survival rate. Anticoagulation treatment for patients with prosthesis placement is still under discussion.

O leiomiossarcoma primário da veia cava é uma neoplasia rara originada das células musculares lisas da túnica média. Representa 2% de todos os leiomiossarcomas e 60% dos tumores de veia cava. Apresentamos o caso clínico de um doente de 64 anos que consultou por lombalgia direita. A tomografia computadorizada revelou grande massa retroperitoneal que envolvia a veia cava inferior e contatava o rim direito; o estudo citológico da biópsia revelou um leiomiossarcoma. O tratamento cirúrgico foi realizado por excisão tumoral e de veia cava inferior com interposição de prótese sintética e nefrectomia direita. O diagnóstico anatomopatológico foi leiomiossarcoma de alto grau sem envolvimento da cápsula renal com bordas de ressecção livres de patologia. A ressecção radical com margens negativas atualmente oferece a melhor taxa de sobrevida. A indicaçãode anticoagulação em pacientes com colocação de prótese ainda está em discussão.

Repermeabilización portal intrahepática luego de ligadura de rama derecha de vena porta: reporte de un caso / Intrahepathic portal revascularization following right portal vein ligation: a case report / Repermeabilização portal intra-hepática após ligadura do ramo direito da veia porta: relato de caso

Resumen: La ligadura de una rama de la vena porta constituye un procedimiento con buenos resultados para evitar la falla hepática posoperatoria en caso de hepatectomías extremas al provocar la hipertrofia del hígado contralateral. Sin embargo, la repermeabilización de ésta ha sido demostrada por la presencia de anastomosis porto portales intrahepáticas, pudiendo determinar una disminución de la hipertrofia esperada o necesaria. Como objetivo documentamos un caso clínico de repermeabilización intrahepática de la vena porta, evento no deseado de la hepatectomía en dos tiempos para el tratamiento de metástasis hepáticas bilobares de origen colorrectal y describimos alternativas para evitar o tratar dicha repermeabilización.

Summary: Left or right portal vein ligation to prevent post-operative liver failure in the case of extreme hepatectomy constitutes a procedure with a good prognosis, as it causes contralateral liver hypertrophy. However, its revascularization has been proved by intrahepatic porto-portal anastomoses, which could result in a reduction of the expected or required hypertrophy. The study aims to record a clinical case of intrahepatic revascularization of the portal vein, an unwanted event of the two-stage hepatectomy to treat bilobar hepatic metastasis of colorectal origin, and describe alternatives to avoid or treat such revascularization.

Resumo: A ligadura de um ramo da veia porta é um procedimento com bons resultados para evitar a insuficiência hepática pós-operatória em hepatectomias extremas por causar hipertrofia do fígado contralateral. No entanto, sua repermeabilização tem sido demonstrada pela presença de anastomose porto-portal intra-hepática, que pode determinar diminuição da hipertrofia esperada ou necessária. Como objetivo, documentamos um caso clínico de repermeabilização da veia porta intra-hepática, um evento indesejado de hepatectomia em dois estágios para o tratamento de metástases hepáticas bilobares de origem colorretal, e descrevemos alternativas para evitar ou tratar essa repermeabilização.

Is Norton Score a useful tool for identifying high-risk patients prior to emergency surgery?

BACKGROUND: Emergency surgery in elderly patients is associated with high mortality rates. Various scoring systems may be valuable in predicting mortality and morbidity rates. It has been suggested that the Norton Score (NS) could be used to quantify frailty. We hypothesized that NS could be a useful tool for identifying high-risk patients before emergency/urgent surgeries. METHODS: A retrospective study was conducted in the Department of Surgery at Kaplan Medical Center, Rehovot, Israel. INCLUSION CRITERIA: age ≥50 years, American Society of Anesthesiologists (ASA) physical status score ≥3 and urgent/emergency laparotomy. A total of 400 patients were identified, and 150 (37.5%) matched the inclusion criteria. RESULTS: A total of 150 patients with ASA scores of 3-5 and who underwent emergent/urgent laparotomy from 1 January 2011 through 31 January 2013 were included. Mean age was 77 ± 9.7 years. The mortality rate at 1 month was 44% (66 patients) and at 1 year was 54.7% (82 patients). A higher ASA score was significantly associated with mortality (P < 0.001). Survivors had lower frailty scores and presented significantly higher preoperative NS (Modified Frailty Index 2.45 versus 3.06, P < 0.05; NS 16.09 versus 12.94, P < 0.01). Preoperative NS was the most significant variable that predicted poor patient prognosis (odds ratio 0.84; 95% confidence interval 0.73-0.96). For ASA 3 and ASA 4, the grade of daily personal independence in activities showed a positive correlation with survival (P < 0.001). CONCLUSION: NS can be a very useful and quick tool to evaluate surgical risk in emergency surgery. Our study supports the use of NS in the perioperative evaluation prior to emergency surgery.

Perforación duodenal asociada a infestación por tenia saginata / Duodenal perforation associated with taenia saginata infestation

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[Positron emission tomography of gastrointestinal carcinomas]. / Résultats de la tomographie par emission de positons dans les cancers de l'appareil digestif.

We evaluated positon emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in 120 patients with intestinal malignancies, focusing on its diagnostic yield and influence on the surgical strategy. PET had a sensitivity of 67% and a specificity of 100% for metastases in 28 patients with cardio-esophageal carcinoma. PET detected 64% of 22 primary pancreatic carcinomas, and had a sensitivity of 70% and a specificity of 83% for metastases. In two cases, PET showed false-positive signs of peritoneal metastasis (not found at laparotomy). Among 70 patients with recurrent or metastatic colorectal carcinoma, eight had signs of local recurrence of rectal carcinoma treated by abdominoperineal resection; PET gave four true-positive, one false-negative, and three false-positive results. PET was better than computed tomography (CT) for the diagnosis of peritoneal metastasis, but its sensitivity was only 58%. The diagnostic value of PET for hepatic metastases (87%) was similar to that of CT (77%) and sonography (87%). The diagnostic sensitivity of PET for pulmonary metastases (82%) was similar to that of CT (84%). PET modified the surgical strategy in two (7%) of 28 patients with cardio-esophageal carcinoma, one (5%) of 22 patients with pancreatic carcinoma, and 22 (33%) of 70 patients with colorectal carcinoma (appropriately in 11 cases, inappropriately in 11 cases). These disappointing results suggest that PET must be thoroughly evaluated in this setting before being widely adopted.

[18 F-fluorodeoxyglucose positron emission tomography for characterization and initial staging of pancreatic tumors]. / Tomographie par émission de positons au (18 F)fluorodésoxyglucose dans l'évaluation initiale des tumeurs du pancréas.

AIM: To evaluate positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) for characterizing and initial staging of pancreatic tumors and to determine its impact on therapeutic strategy. PATIENTS AND METHODS: This study included 24 patients with pancreatic tumor who underwent PET before treatment. Twenty-two patients had a malignant tumor and two had a benign tumor. The PET scan was performed after intravenous injection of FDG with a gamma camera. PET findings were compared with histology of the pancreatic tumor (n=24), liver metastases (n=5), peritoneal metastases (n=5), and lymph node metastases (n=5). Absence of metastasis or lymph node involvement was determined by surgery or by CT scan, ultrasonography, magnetic resonance imaging and at least two months follow-up. RESULTS: The sensitivity of the PET scans to identify pancreatic carcinoma was 64% (95% confidence interval 44-84%). PET scans could not be interpreted for lymph node involvement adjacent to the tumor. For liver metastases, the PET scan was positive in 3 out of 5 patients. For peritoneal metastases, the PET scan was positive in 4 out of 5 patients but was doubtful in one. There were two false positives. Among the 4 cystic tumors, the PET scan was positive for 2 malignant tumors and negative for 2 benign tumors. Surgical strategy was modified in only one of the 24 patients on the basis of PET findings. CONCLUSION: The sensitivity of PET for the diagnosis of primary malignant pancreatic tumor was found to be low. The contribution of FDG-PET to the surgical decision appears to be limited to the detection of metastases or lymph node involvement distant from the tumor, contraindicating surgery. Nevertheless, the sensitivity of FDG-PET is lower than that of laparoscopy for peritoneal metastases. Indications for PET should be included in an evaluation of therapeutic decision making and cost analysis.

Modelo experimental de catéteres venosos centrales en alimentación en ratas / Experimental model of central venous catheters for nutrition in rats

Se realizó un estudio prospectivo en el que se analiza un modelo experimental de vía venosa central en la rata. En el mismo se analiza la técnica, complicaciones y su aplicabilidad. Encontrándose una disparidad en las complicaciones en relación a trabajos de autores previos; concluyendo que la técnica empleada es aceptable para experiencias de corta duración en los que sea necesario el empleo de accesos venosos centrales

Cambios estructurales intestinales en la desnutrición y la injuria moderada / Intestinal structural changes in malnutrition and moderate injury

Hemos realizado un estudio prospectivo en el que se analiza el efecto de dos variables: la desnutrición simple y la injuria moderada, representada por la colocación de una vía venosa central, sobre la morfología intestinal en un grupo de ratas. Los resultados fueron estudiados por test de "T" poniendo especial atención a nivel de la altura de la vellosidad intestinal, profundidad de la cripta y número de mitosis en relación al peso del animal, observándose que no existen cambios significativos a nivel del grupo control ni en los sometidos a injuria y desnutrición