Abdominal cocoon is a rare disease which causes small-bowel obstruction that is characterized by a thick, fibrotic and cocoon-like membrane encapsulating total or partially the small bowel1,2,3. Its etiology remains unknown4,5. Surgical management is the treatment of choice1. In this report, it is described a young patient with abdominal cocoon who presented clinical signs and paraclinical findings of intestinal obstruction.
In July 2010 a 25 year-old man was admitted with 2-month history of intermittent colicky abdominal pain and bilious vomiting and abdominal distension. He also complained from chronic constipation, anorexia and 14 kg weight loss during the previous two months. He had no surgical or other medical history except using of a body building supplement drugs which contain creatin.
Hepatocellular adenoma (HA) is a rare benign neoplasm of the liver. It is strongly associated with oral contraceptive used by woman in childbearing age, by men receiving anabolic steroids and metabolic diseases. HA incidence has raised over the years from 5 per 1 milion in 19649 to 4 per 100.0003 , for unknown reasons.
HA is important because of its risk of complications such as life threatening rupture of the tumor and malignant transformation. Surgical treatment in ruptured HA has a high mortality rate but it is still the standard procedure in those cases5. Emergency liver resection in ruptured HA has a mortality rate from 5-10%, but in elective resections the mortality rate is under 1%.
Different procedures have been suggested to decrease mortality rates and spare liver parenchyma, such as arterial embolization of ruptured adenomas, although it is not an available procedure in most centers.
A 44-year-old woman admitted in the emergency department of another hospital with complaints of sudden upper quadrant abdominal pain. She had been using oral contraceptives for 31 years. She presented with acute mild abdominal pain in epigastrium as well as right hypochondrium pain followed by light dyspnea and dizziness. She was treated with analgesics and ordered an abdominal ultrasound made only three days after the pain. The ultrasound showed a solid liver mass in the right hepatic lobe measuring 150x100x100 mm3. She was discharged without additional treatment.
After almost five months after the occurrence, she was referred to our surgical department for diagnostic investigation after another episode of abdominal pain just like the last time, followed by tachycardia and cold sweating. Physical examination revealed mild anemia and a diffuse abdominal pain, without peritonitis or palpable masses.
Lab exams showed 8.61g/dl haemoglobin, white blood count 8.980/mm3 and 214.00 platelets. Liver transaminases level were altered: ALT 306 IU/l, AST 154 IU/l, alkaline phosphatase 142 IU/l and gamma-glutamyl transferase 229 IU/l. Alfa-fetoprotein and clotting functions were normal.
The congenital diaphragmatic hernia (CDH) is defined as an anatomical defect on diaphragm, which permits the herniation of abdominal viscera into the thorax4. The hernia occurs due to an incomplete occlusion of the pleuroperitoneal channel during the embrionary period. The main cause of the incomplete closure can be a genetic mutation, a teratogen or both.
In terms of anatomic location, the CDH can be classified as Bochdalek type when an incomplete pleuroperitoneal channel occlusion is found posterolaterally; as Morganni type, while the defect is seen retrosternally; and yet as a congenital transhiatal esophagic type hernia. Among them, the Bochdalek type is the most common, found in 78-90% of patients; the Morganni type, in 1,5-6% of cases; and transhiatal, 14-24%11.
In most cases, the clinical impact occurs in the neonatal period, since only 10% of hernias are diagnosed after this period7. In neonates, the clinical presentation is acute, providing a higher morbidity and mortality. In adulthood, symptoms, if any, are more insidious, vague and intermittent, affecting not only the pulmonary dynamics, but also the gastrointestinal function5.
Chest X-ray and CT scan may be used2,8,12.Nevertheless, CDH findings are incidental when performing radiological examinations for other reasons, with the right-sided Bochdalek hernia accounting for 68% of cases.9,13
In elective situations, the minimally invasive surgery, either via laparoscopic or thoracoscopic can be used, but with limited application in cases of right-sided hernia3,8. Minor defects, technically easier to fix, can be sutured normally; in the case of larger apertures, or even hemidiaphragmatic agenesis, the use of nonabsorbable polypropylene mesh is the only solution.
The cryptorchidism is the most common congenital malformation of the genitourinary tract4. The intra-abdominal testicle is subject to complications such as cancer, ischemia and infertility1. The most common malignant transformation of undescended testicle is the seminoma2,3,5. Here is presented a case of adult massive pelvic mass corresponding to seminoma developed in intra-abdominal testis.
MC'S, man, 32, with a history of progressive and painless increased abdominal size four weeks ago, no other complaints. He had also several congenital malformations including: pectus excavatum, congenital dislocation of the hip and clubfoot (operated in childhood). Physical examination revealed ascites, bilateral pleural effusion and a hardened mass located in flank and the right iliac fossa of about 20 cm. Was detected the absence of the right testicle in scrotum. No abnormal laboratory tests were present. Computed tomography and magnetic resonance imaging of the abdomen and pelvis showed ascites and heterogeneous pelvic mass (Figure 1). The cytological study of ascites and pleural effusion showed no neoplastic cells.
Celiac axis compression syndrome, also known as median arcuate ligament syndrome or Dunbar syndrome, is a rare condition. This syndrome was first reported by Harjola in 19636. Dunbar described it as a clinical syndrome in his memorial paper in 19654. It is characterized by compression of the celiac axis by the median arcuate ligament of the diaphragm.
The median arcuate ligament is a fibrous arch formed at the base of the diaphragm at the level of the 12th thoracic vertebra, where the left and right diaphragmatic crura join1. This fibrous arch forms the anterior aspect of the aortic hiatus, through which the aorta, thoracic duct, and azygos vein pass. The median arcuate ligament usually comes into contact with the aorta above the origin of the celiac axis. However, in some individuals, the it may be abnormally low and passes in front of the celiac axis, causing its compression, which is named median arcuate ligament syndrome5.
Some patients with this syndrome refer severe clinical manifestations such as postprandial abdominal pain, weight loss, and vomiting. The primary treatment modality for this condition is surgical division of its fibers. The traditional surgical approach has been through an upper abdominal laparotomy incision. Roayaie et al. in 2000 reported the first patient with celiac axis compression syndrome treated by laparoscopy access. Afterwards, several authors have demonstrated that the laparoscopic access may be employed with success to treat this condition8. To best of our knowledge, this is the first report of laparoscopic treatment of the celiac axis compression syndrome in Brazil.
Verrucous carcinoma is a very rare type of squamous cell carcinoma, slow-growing and found in the oropharynx, larynx, penis, scrotum, vulva, vagina, cervix, endometrium, bladder and anorectal region. It is believed to be related to chronic irritation or inflammation of the mucosa due to smoking, drinking, achalasia, esophagitis, ingestion of lye or esophageal diverticulum.
The main symptom is dysphagia, associated with great weight loss. Patients are usually admitted in an advanced state of malnutrition, especially due to delays in diagnosis, leading to high surgical risk and mortality1,2,4,5,6,7,8,9,10
Man aged 64, smoker for 44 years, having stopped for 16 years. He presented with rapidly progressive dysphagia, from solid to liquid in four months, associated with weight loss of 18 kg in the period.
Initially admitted for investigation at another facility where he underwent upper gastrointestinal endoscopy, which showed whitish plaques in the entire esophagus and biopsies showing Candida sp. He was treated with intravenous antifungal and remained hospitalized for 28 days, but there was no improvement of the dysphagia, on the contrary, it progressed to inability to swallow saliva. A new endoscopy revealed growth of a vegetative mass in the mucosa and it was not possible to reach the stomach. A nasogastric feeding tube was inserted at this moment. Again biopsies were taken and the results showed no malignancy.
Gallstone ileus (GI) is a rare complication of biliary pathology when a bile stone from gallbladder or exceptionally from the main bile duct, cause an obstruction of the intestinal lumen10. Gallstone ileus incidence has remain constant through the years in 0,9 cases for 100.000 admissions/year6.
The diagnosis is usually difficult because of the abscense of specific symptoms, and sometimes by the partial remission of them during the migration of the bile stone through the intestinal lumen. This situation usually delays the consultation until there is greater compromise of the patient´s general condition. The imaging studies, either simple radiology, ultrasound or computarized axial tomography of the abdomen are useful in the early diagnosis1. The initial treatment for GI is the reanimation and stabilization of the electrolite imbalance that might present on this patients and later perform the surgical resolution of the bowel obstruction.
The objective of this report is to present the finding of a gallbladder cancer in the two-stage resolution of a GI and discuss some aspects about the treatment of this disease.
We read with special interest the article by Schnitzbauer et al. 4 published on March 2012. We believe that this paper is a cornerstone in hepatic surgery, bringing a new method which can greatly contribute do increase resectability in patients once outside of surgical therapy.
Surgical resection remains the treatment of choice for patients with primary and secondary liver tumors, representing the only chance to obtain long-term survival 1 . Nowadays, with improvements in surgical expertise, anesthesia and postoperative care, no limits due to number of lesions and location are of value as in the past 5 .
Since the original cited report, some technical changes in ALPPS procedure (Associating Liver Partition and Portal vein ligation for Staged Hepatectomy) were described. Despite the initial enthusiasm with the new technique, several centers worldwide showed that, when properly indicated, the morbidity related mainly to the first surgery is high 2 . The release of hepatic ligaments and the transection of the liver parenchyma when the division of segments III and IV is often responsible for increased blood loss, biliary fistula and high operative time.
Thus, based on our previous experience with the use of bipolar radiofrequency with cold needles (BRCN) in performing hepatectomies 3 , coupled with our enthusiasm with this new two-staged technique, we decided to replace the hepatic parenchyma transection by making two lines of denatured liver tissue by radiofrequency, isolating the future liver remnant (FLR) in a similar way of surgical transection, more quickly, easily, with no hepatic mobilization and less blood loss.
This is a report of an initial experience, which we call ALRPS - associating liver radiofrequency and portal vein ligation for staged hepatectomy.
Fistula from esophagojejunostomy is still one of the most feared complications after total gastrectomy. Despite the development of new surgical devices and techniques, it remains a major concern with an incidence around 5%10. The use of endoscopic stents has brought the possibility of another form of fistula treatment3. However, this technique hasn´t yet been fully incorporated into clinical practice. This article describes a case of an esophagojejunostomy fistula that was successfully treated with an endoscopic stent. A literature review about this issue also follows.
A 61- year-old male patient was diagnosed with an infiltrative 6 cm tumor located in the lesser curvature of the medium gastric body invading cardia. The biopsy revealed a diffuse adenocarcinoma with signet-ring cells. Co-morbidities included morbid obesity (BMI 40.8) and arterial hypertension. Staging CT-scan showed a thickening of the gastric lesser curvature without any lymph node enlargement. The patient underwent total gastrectomy with D2 lymph node dissection and Roux-en-Y reconstruction. Esophagojejunal anastomosis was performed with a 25 mm circular stapler with intact resection rings. No leakage occurred after methylene blue testing. The anastomosis was drained with bilateral tubular silicon drains. On the 5th postoperative day, the patient presented diffuse abdominal pain and drainage of enteric fluid in the tubular abdominal drain. A CT-Scan with oral contrast demonstrated a leakage in the anastomotic area as shown in Figure 1.
Since it was an early fistula associated with peritonitis, an exploratory laparotomy was performed and revealed a suture dehiscence of 40% of the posterior wall of the esophagojejunal anastomosis. No specific local factors were noted that could explain the early occurrence of the fistula. Latter, the patient confessed unauthorized drinking of liquids since the first postoperative day. A suture of the dehiscence area was performed along with a nutritional jejunostomy, nasoenteric tube for decompression, and drainage of the cavity. Two days after the revisional surgery, leakage of enteric liquid in the abdominal drain occurred again, but without clinical signs of peritonitis. After discussion and evaluation of the patient clinical status, it was decided for a non-surgical treatment of this recurrent fistula. Patient remained stable with antibiotics, parenteral and enteral nutrition.
The coronavirus disease 2019 (COVID-19) pandemic was identified in Brazil in February 2020. The first Brazilian case was reported on February 25, 20204, and since then, the number of cases increased dramatically, placing Brazil among the countries with the largest number of infected patients and the largest number of deaths from the new coronavirus (>600,000) (4)
A total of 3,000 patients with moderate or severe COVID-19 were admitted to the Hospital de Clinicas of the School of Medicine of the University of São Paulo for in-hospital treatment. Following the recommendations of its infection committee and the main medical societies, all nononcological elective surgeries were suspended.
From 2008 to 2018, the Cancer Institute performed over 8,500 surgeries for colorectal cancer. In this new scenario, although the number of surgeries was reduced to avoid including contaminated patients, some procedures cannot be canceled or postponed; this is especially the case for procedures performed at the Cancer Institute, given the need for continued oncological treatment in both elective and urgent cases. A contingency plan was, therefore, established to allow us to proceed with surgeries that cannot wait due to the risk of disease progression and worsening of the prognosis.
Three patients with colorectal cancer underwent elective (one patient) or urgent (two patients) surgical treatment in April 2020, and they were diagnosed with COVID-19 only during the postoperative period.
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