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Carbohydrate antigen 19-9 (CA 19-9), first described in 1979, is a cell surface glycoprotein complex produced by ductal cells in the pancreas, biliary system, and epithelial cells in the stomach, colon, uterus, and salivary glands19. Its expression is only observed in patients with Lewis antigen (Le) A−B+ or Le A+B− blood groups. Up to 6% of the Caucasian and 22% of the non-Caucasian population are genotypically Le A−B− and therefore do not produce CA 19-919.
CA 19-9 is overexpressed in many benign and malignant, gastrointestinal, and extra-gastrointestinal diseases. Its main implications are in pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasm (IPMN), but it can also be elevated in biliary, hepatocellular, gastrointestinal, urological, pulmonary, gynecological, thyroid, and salivary gland cancers16. Benign conditions in which CA 19-9 may be elevated include pancreatitis, pancreatic cysts, diabetes mellitus, liver fibrosis, benign cholestatic diseases, and other urological, pulmonary, and gynecological diseases15.
The aim of this article was to present a case of an asymptomatic and exuberant elevation of the CA 19-9 with no identified etiology and a review of the clinical use and implications of the CA 19-9.
Chylous ascites is a rare disorder characterized by the accumulation of triglyceride-rich fluid in the abdominal cavity due to the disruption of the lymphatic system2,3,11. A variety of conditions can cause chylous ascites, including congenital lymphatic abnormalities, inflammatory and infectious conditions, liver cirrhosis, malignancies, cardiogenic trauma, and iatrogenic injury postsurgery2,8. The fluid of chylous ascites has a “milky” appearance, and the triglyceride content is over 110 mg/dL2,11. Chylous ascites cause mechanical symptoms related to abdominal distension and may lead to malnutrition and impairment of the immune system that is associated with morbidity and mortality. The prognosis is different in chylous ascites and can be fatal depending on the underlying cause. High mortality rates have been observed in up to 90% of patients with cancer if not treated properly1,4,11.
There is no standardized treatment of chylous ascites, and the current management includes high-protein and low-fat diet as conservative treatment, total parenteral nutrition (TPN), paracentesis, radiology, and surgical interventions. Lymphangiography and percutaneous embolization are a less invasive procedure and have been reported to have a therapeutic effect in 56–86% of patients with lymphatic leaks1,2. Intranodal lymphatic embolization has been previously described in the treatment of some visceral lymphatic leaks1,5,13. This study aimed to present a case of chylous ascites after pancreatoduodenectomy treated with lipiodol lymphangiography and embolization.
Multiorgan dysfunction involving the liver and kidneys is common in patients with end-stage heart failure. The first combined liver-kidney transplant (CLKT) was performed by Margreiter in 1983, and it is a routine procedure in many transplant centers representing 1-8% of liver transplant candidates5.
Hepatic and renal dysfunction may be secondary to a systemic disease process affecting the heart, liver, and kidneys or may be a consequence of heart failure with venous congestion and arterial hypoperfusion2,4.
Despite the complexity and costs involved, the results of this type of transplant are optimistic, as these are terminally ill patients.
Our objective was to report the first Latin American experience in triple transplantation in the same surgical time (heart, liver, and kidney), which took place at Hospital São Lucas Copacabana1.
The organ receiver was a 56-year-old male, physical education teacher, diagnosed with dilated cardiomyopathy with biventricular dysfunction of undetermined origin and compensated cirrhosis of probable cardiogenic etiology diagnosed in 2018 during a cholecystectomy. Chronic kidney disease was due to cardiorenal syndrome.
After follow-up of the case, triple liver-cardiac-renal transplantation was indicated.
Pancreatoduodenectomy after neoadjuvant chemotherapy is the current treatment in patients with borderline pancreatic ductal adenocarcinoma in the head of the pancreas1,2,3. The total mesopancreas excision concept includes the resection of the lymphatic structures on the right side of the SMA and along the neuronal plexus of the pancreatic head. Complete clearance of this retroperitoneal area may increase the R0 resection rate in patients with adenocarcinoma in the head of the pancreas. This area is an important location of perineural infiltration of tumor cells in patients with pancreatic ductal adenocarcinoma4.
Hackert et al5 described the term “triangle operation” as a new surgical technique for patients with locally advanced pancreatic ductal adenocarcinoma and stable disease following neoadjuvant therapy. This area is defined by SMV/PV, celiac axis/common hepatic artery, and SMA, representing the typical view after completion of the resection. However, according to the definition of the authors, the procedure should be performed without arterial resection. Recently, Loss et al6 and Schneider et al7 observed that arterial resection is effective in patients with locally advanced pancreatic cancer after neoadjuvant chemotherapy, with better long-term survival than with palliative treatment. However, this procedure should be performed in experienced pancreatic centers. After neoadjuvant chemotherapy and centers with expertise in pancreatic resection, arterial resection is perfectly possible with acceptable morbidity and mortality.
Signet-ring cell (SRC) carcinomas are poorly-differentiated malignant tumors that may affect the stomach and the colon, but very rarely occur in other digestive organs1,3. Although SCR distal bile duct cholangiocarcinomas have been very rarely reported2,4,7 we herein first report the occurrence of a SRC hilar cholangiocarcinoma.
A 66-year-old caucasian woman was admitted with a 40-day history of fatigue, anorexia, jaundice, itching and pale stools. She had undergone external percutaneous transhepatic drainage and had been treated for cholangitis with antibiotics. The patient had no palpable masses and her past medical history was unremarkable. Total bilirubin and liver enzymes were mildly elevated, and CBC was normal. Abdominal computed tomography showed a 4.0 x 0.5 cm tumor on the confluence of the right and left hepatic bile ducts with moderately dilated intrahepatic ducts. It also revealed a 2 cm tumor in the left kidney. Additional workup was negative for metastases.
Laparotomy was performed and revealed a hardened mass involving the common bile duct from above the implantation of the cystic duct to the confluence of the right and left hepatic ducts. Resection of the biliary tree was then carried out from the supraduodenal portion of the common bile duct to the first 2 cm of the right and left hepatic ducts, with en-bloc regional lymphadenectomy. A Roux-en-Y jejunal loop was taken to the hepatic hilum and right, left and caudate bile ducts were sewn to a single jejunal loop.
Macroscopic exam of the bile duct tumor revealed a 5.5x0.8cm surgical specimen that was firm and scirrhous tumor located on the confluence of the right and left hepatic ducts (Klatskin tumor). Bile duct confluence had a narrow lumen but no stones or mucin. Gallbladder had no stones or wall thickening.
Meckel's diverticulum is the most common malformation of the gastrointestinal tract with an incidence of 2% of the population. This congenital anomaly results from incomplete yolk duct development1. Meckel's diverticulum has a complication rate of 4-6%. Most common complications are haemorrhage, perforation, obstruction and inflammation4. It is mostly asymptomatic and most often diagnosed when complications occur. Also it may be diagnosed incidentally during laparoscopy or laparatomy for unrelated conditions1.
Fistula formation (between abdominal organs), herniation (of abdominal wall), and Littre hernia (protrusion of a Meckel's diverticulum through an abdominal wall defect) are well-described complication. However, umbilical herniation of Meckel's diverticulum is rare3. Herein is presented a case with enterocutaneous fistula between Meckel's diverticulum and umbilicus associated with umbilical hernia.
A 40-year-old man was admitted to the department of General Surgery with a 24 h history of abdominal pain focused on the umbilical region, as well as fever, anorexia and vomiting. He had a history of previous umbilical abscess drainage five years ago. He reported no other medical history. Examination of the abdomen showed tenderness over the umbilical region without abdominal guarding and rigidity. A leakage of intestinal fluid through an opening (an external fistula orifice) was determined inside the umbilicus. There was no increase in local heat, swelling or edema. The laboratory findings, including complete blood count and electrolytes, and abdominal X-ray showed no abnormality. Abdominal ultrasound showed a well-limited liquid collection of 1.5x1.5 cm subcutaneously under the umbilicus. The contrast-enhanced abdominal computerized tomography scan revealed a small intestine segment lying subcutaneously throughout the fascia defect on the umbilicus The intestine was fistulized throughout the umbilical hernia into the external layer of the skin (Figure 1). With the clinical and radiological findings, the patient was initially diagnosed as enterocutaneous fistula with a Meckel's diverticulum. In the surgery, abdomen was opened and the exploration revealed Meckel's diverticulum (lying subcutaneously throughout the fascia defect on the umbilicus) and a fistula between this and the umbilicus. There was no fluid contamination in the abdomen. A diverticulectomy and an excision including the fistula tract and umbilicus were performed (Figure 2). The patient was discharged at fifth postoperative day safely. Histopathologic examination approved Meckel's diverticulum.
Injuries that affect the presacral space are rare, and are part of a heterogeneous group of entities of primary concern to colorectal surgeons. These lesions are located in anatomically difficult area to be addressed, hence the need for prior surgical planning, as well as knowledge of the major diseases that affect this region.
The incidence of these lesions varies from 1: 40.000 to 1: 630,0007, being more common in females between 40 and 60 years8.
Man of 94 years showed changes in bowel habits few months ago. Digital rectal examination showed solid pelvic mass with no apparent invasion of the rectal mucosa; it is not possible to predict its upper limit. Computed tomography of the pelvis showed solid-cystic lesion in proximity to the sacrum bone and rectum, with apparent cleavage plane between adjacent structures (Figure 1). He underwent transperitoneal resection of the lesion. Major bleeding occurred during surgery, which was controlled, requiring blood transfusion with four blood cell concentrate units.
Gastric cancer sets among the five most prevalent cancer in Brazil. For the year 2014, according to the National Cancer Institute (INCA), were expected 20,390 new cases with 13,328 deaths from the disease3.
Despite the identification of risk factors for the occurrence of neoplasia1, approximately 80% of cases are sporadic and not associated with risk factors. Even less frequent, it is the hereditary cases and associated with mutation of the HRC 1 gene, determining the occurrence of Cancer Hereditary Diffuse Gastric Syndrome. It corresponds to 3% of cases of gastric cancer7,10.
Patients mutation CDH1 gene carriers have shown gastric cancer with more adverse prognosis, as the presence of signet ring cells, poorly differentiated tumors and diffuse histological pattern, making also important to identify families suffering from chromosomal gene changes and syndrome determinants to allow early diagnosis and preventive treatment7,10.
As for the surgical treatment of hereditary or not gastric cancer, laparoscopy has demonstrated oncologic results similar to laparotomy approach, and lower morbidity, with patients returning earlier to their activities4.
This study aims to report a case diagnosed clinically and genetically, with treatment done through laparoscopic radical gastrectomy.
Man with 33y was admitted in July 2012 at the General Surgery Service of the Hospital of the Military Police of Paraná, asymptomatic and without comorbidities, but with a family history of gastric cancer in reporting two first-degree relatives with a diagnosis of cancer, one of them younger than 50 years (Figure 1A). After the endoscopy (Figure 1B), was identified ulcerated lesion in the gastric body with positive pathology for adenocarcinoma with histological pattern of signet ring cells (Figure 1C).
Traumatic diaphragmatic hernia (TIH) develops in association with blunt or penetrating thoracoabdominal injuries. Incidence levels between 0.8% and 42% have been reported, depending on the injury site1,9,12,13. TIH is a rare entity. It occurs either due to trauma-related diaphragmatic injuries which cause tears in the intercostal muscles between the fractured ribs, or due to recurrence of diaphragmatic hernia in which previous repair was performed using the transthoracic approach1.
Traumatic diaphragmatic injuries are generally asymptomatic when isolated, and frequently cannot be detected radiologically under acute conditions13. When accompanied by other organ injuries requiring surgical exploration, diagnosis is made during operation, and these can be treated concurrently. Laparoscopic repair is usually preferred in acute isolated diaphragmatic injuries, while chronic and recurrent cases are traditionally repaired using thoracotomy because of dense adhesions. With increasing experience of minimally invasive surgery in recent years, it has been reported that chronic and recurring cases can also be laparoscopically treated.
No cases of laparoscopic repair in simultaneous recurrent chronic traumatic diaphragmatic hernia (RCDH) and TIH have been reported to date. Here, is described the laparoscopic repair of this association.
Gastrointestinal bleeding due to gastric neoplasia is difficult to manage and may provoke dramatic situations. For the most part, therapeutic endoscopic methods provide only temporary success in controlling bleeding. Often, a poor clinical condition and an advanced stage of the neoplastic disease mean these patients will receive exclusively palliative clinical care. Hence, surgical procedures are often contraindicated, either due to lack of clinical conditions or the increased mortality resulting from surgical trauma. In such cases, alternative endoscopic techniques have been described as minimally invasive means of controlling tumor-induced bleeding.
A 79 year-old man with gastric GIST, receiving Imatinib for the presence of multiple hepatic (Figure 1), pulmonary and bone metastases, was admitted to the Cancer Institute of the University of São Paulo Medical School,São Paulo, SP, Brazil after presenting massive hematemesis, followed by syncope.
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