INTRODUCTION

The gastrointestinal stromal tumor (GIST) is a rare type of tumor that expresses CD117 oncogene that can be detected by immunohistochemistry². The most common sites of GISTs are stomach (70%), and small intestine (20%), while rectum is comprised in only 3% of the cases⁵. Although a rare condition, the GIST located in the distal rectum may require an abdominoperineal resection. There is no data to support the use of Imatinib (Gleevec from Novartis, Basel, Switzerland), a selective inhibitor of tyrosine quinase, as neoadjuvant therapy. However, the last session consensus for the treatment of GIST, suggests that this form of therapy can be used in some cases where anal sphincter is involved⁷. The objective of this report is to describe a case of GIST distal rectum in the rectovaginal septum with partial invasion of the anal sphincter, which was successfully treated by neoadjuvant therapy with imatinib followed by the technique of transanal endoscopic microsurgery (TEM). The results are compared with experience in the literature.

CASE REPORT

A 63-years-old female patient was sent to the hospital with complaints of mild constipation. A clinical examination did not detect any palpable abdominal mass. Rectal digital exam revealed a 5 cm mass in the left anterior rectal wall, located 2 cm above the dentate line. The mass was solid, with a smooth and regular surface. Colonoscopy confirmed the presence of a round and regular mass, covered by normal mucosa, measuring about 5 cm in diameter, in the left anterior wall. A transrectal biopsy with Tru-cut needle was performed. Immunohistochemical positivity for CD117 and CD34 antigens, and negative for smooth muscle actin or S-100 protein confirmed the diagnosis of a submucosal rectal GIST. The mitotic activity was 2×10 high power field (HPF), and there was absence of necrosis. Computed tomography showed the presence of a tumor of 5.2x5.0x5.6 cm, irregular, with eccentric thickening of the left anterior rectal wall in the lower rectum, with close contact with the posterior vaginal wall and partial invasion of the levator ani muscle, but with no evidence of lymph node or distant metastases (Figure 1).

The spleen, since antiquity, is an organ little known in its duties¹^,³. We conclude that all its physiological role is not known; but what is known, is that it is essential, verified through other means, by post-splenectomy sepsis for example⁴^,⁵.

Anatomical studies developed by Neder, AM⁷ and Zapala, A.²⁶, guided by DiDio and anatomical dissections by Campos Christo², guided by Resende Alves²², led to the conclusion that the spleen has independent territories under vascular standpoint. There are five. The upper pole is supported by the phrenoesophageal membrane and few phrenic vessels and the inferior pole presents the splenic-gastric membrane, sectorial pedicle and the spleno-colic ligament. There is, therefore, greater anatomical integration of inferior pole with the visceral abdominal compartment, mainly with left upper quadrant⁶^-⁸.

Young stabbing victim forced Campos.Christo² to have the opportunity to realize the first partial splenectomy (ruled) successfully. The fact spread and today, injured spleen is maintained spleen⁹^-¹⁴.

We had the opportunity to implant spleen fragments experimentally and all took completely. Petroianu discussed with me, but did not accept the suggestion and decided to investigate the upper pole on excellence studies¹⁵^-²¹ on its remaining function after ruled splenectomy.

COMMENTS

Dear Editor:

We have read with interest the recently research published by Nunes EC et al¹ and we believe that this is a very interesting study considering how prevalent is gallbladder calculus disease in Latin America. However, we would like to make some comments, as there are some aspects that can be discussed.

Can cholecystitis and cholelithiasis be integrated into the same universe? We believe not. The first is an emergency condition and requires, according to its state at the time of admission, previous medical treatment and surgery, which can be postponed and re-enter in some other time; the second is an elective admission. Cholecystitis will be more likely to have more hospitalizations than cholelithiasis, surgical solution decreases the number of hospitalizations.
The authors refer to, as one of the variables of the study, the total number of hospitalizations, but it is not well understood why the "hospitalization/general population" indicator, as the proportional difference of this relative frequency is the same as the absolute number. It is more convenient to measure the specific rate of hospitalizations by age group that makes the economic analysis of the in-hospital stay more realistic. It is also useful to measure the concentration of hospitalizations by case and adjust it by variables that may be confusing such as socioeconomic status, educational level, purchasing power, nutrition education, adherence to treatment; the latter is at the same time influenced by work schedule, food culture, and the ability to decide the home meal. These variables that could be intervening are not being analyzed in the study: the number of times of in-patient admission, and the hospital stay. For a more updated economic analysis, medical expenses are no longer made on the basis of an event but on the basis of a case, therefore it is necessary to differentiate hospitalizations per incident case to not confuse hospitalizations of prevalent cases. This improves the economic analysis and allows to propose interventions on the issue of costs of hospitalization for cholecystitis and cholelithiasis.
Regarding the severity of gallbladder calculus disease, the authors hypothesize that gravity would be associated with the anthropometric characteristics, distribution of body fat and pain threshold; however, on this point there are other variables that may explain the severity conditions in patients coming to the emergency services and these are due to other variables such as self-medication, access to health services, patients' idiosyncrasies, among others; which often involve a delay in attending a hospital with a consequent increase in the severity of cholecystitis.
In terms of mortality, this was elevated in the elderly; probably associated with comorbidity, greater severity of the disease at hospital admission and less physiologic reserve, feature of this patient group; on the other hand there wasn't any exclusion criteria, which means there were mixed diagnoses such as cholangitis, gallbladder cancer, acute pancreatitis, among others. Additionally, early cholecystectomy in these patients could result in morbidity up to 41% and perioperative mortality up to 18%².
Considering the surgical average time of the open and laparoscopic cholecystectomy, it is claimed to be similar between the elderly and the young; however, we must differentiate between an elective or an emergency surgery for these groups of people; it is known that the elderly have an increased presence of risk factors for conversion of laparoscopic cholecystectomy to open surgery as fibrosis of the gallbladder wall due to repetitive cholecystitis which likewise causes a retracted gallbladder, increased likelihood of adherence syndrome by the history of previous surgeries³.
There was restriction on the study to not established if the surgery was performed on the context of an elective or emergency surgery, the study refers or distinguishes cholecystitis and cholelithiasis, so that could indirectly approach more accurate data distribution, which means that the patients with cholelithiasis are candidates for elective surgery and patients with acute conditions, meaning cholecystitis go to emergency surgery; an analysis from this point of view would have been more enlightening and not analyze it as a whole. The study doesn't classify patients according its severity, i.e. Acute Cholecystitis grade I, II or III according to Tokyo guidelines, therefore we cannot tell whether the treatment was early, late or in between, which may affect mortality.
It is referred that there was a major expense on children under 4 years coursed with cholelithiasis or cholecystitis, probably due to the oddness of thinking of cholelithiasis as a diagnosis in this group and it also requires further studies and a more complex treatment than adults⁴.

INTRODUCTION

Central hepatectomy (CH) is also known as mesohepatectomy and means hepatic resection of segments 4, 5, and 8⁹. Hepatic lesions located in these segments may require extensive resections, such as right, left, extended right or extended left hemi-hepatectomies especially due to their relationship to major vascular and biliary structures. CH represents a potential risk of intraoperative bleeding, biliary injury, and risk of positive margins, but also represent the appealing concept of parenchyma sparing, furthermore in benign lesions.

Is reported a case of a symptomatic patient with a large complex cystic tumor who underwent a CH without tumor violation and no major postoperative complication.

CASE REPORT

A 61-year old female patient with history of choluria, acholic stools, jaundice and pain in the right upper abdominal quadrant had undergone a cholecystectomy and hepatic cyst unroofing by laparotomy in another institution, 30 months ago. Due to the cholestatic symptoms recurrence, she was refered to our center.

Abdominal MRI showed a cystic lesion in segment 4 with septa and thickened walls, and measuring 9.0 cm. The cyst was demonstrated as isosignal on T1 and hyperintense signal on T2. The confluence of left and right bile ducts was compressed by the cyst, which caused moderate bilateral dilation. The lateral limit of the cyst compressed the left hepatic artery and the left branch of the portal vein, while its lower limit compressed the right portal branch and the right hepatic artery. Other non-complex cystic lesions were scattered through the liver (Figure1). Laboratory tests showed increased canalicular enzymes and bilirubins and negative tumor markers. The case was reviewed at a weekly hepatobiliary multidisciplinary conference and the main hypothesis was a recurred biliary cystadenoma. In order to avoid a right trisectionectomy the decision was to perform a parenchymal preserving resection - central hepatectomy.

INTRODUCTION

Malignant anal melanoma is a rare disorder, corresponding to 0.05-1.0% of all anorectal tumors, and 0.4-1.6% of all other melanomas⁷^,⁸^,⁹. Its rarity can be confirmed by the fact that for every anal melanoma, there are eight squamous cell carcinomas and 250 anal adenocarcinomas⁸^,⁹.

The article´s aim is to present a case of a malignant anal melanoma coexisting with colon adenocarcinoma, in addition to a discussion on how to speed up the diagnosis with simple routine measures, and report an objective treatment.

CASE REPORT

A 57-year-old patient was admitted with weakness, pale skin and a lump in the inguinal region. According to his medical history, one year prior to admittance the patient was treated for anemia. At the time, he presented positive fecal occult blood test. Endoscopy and contrast exams were normal and no weight loss or changes in bowel movements were noticed.

In the six months prior to admittance, the patient felt sporadic pain in the anal canal that ceased with the use of NSAID suppositories. After 30 days, he sought medical attendance and underwent proctosigmoidoscopy and colonoscopy, along with biopsy of lesions in the anal canal and cecum. The patient was then diagnosed with poorly differentiated carcinoma of the canal and well differentiated tubular adenocarcinoma of the cecum. At the time, a lump began forming in the root of the thigh, just below the inguinal fold.

The patient was refered to Sírio-Libanês Hospital in São Paulo, Brazil, for surgical treatment of the colon lesion and clinical treatment of the anal canal lesion (Figure 1), as he refused to operate the anal lesion. Abdominal ultrasonography and thorax tomography did not reveal any findings. Surgery was then performed with right ileocecal colectomy, intra-operatory biopsy of lesion in the anal canal and of the right inguinal lymph node.

INTRODUCTION

Pancreatic cancer surgery is a technical challenge to the modern abdominal surgeon. Vascular resections, especially venous resections, have become frequent in specialized centers, accounting for 15-70% of duodenopancreatectomies and Appleby procedures for adenocarcinoma¹¹.

In Brazil, pancreatic cancer represents the seventh cause of death due to neoplasm in men and the sixth in women⁹.

The religious group of Jehovah's Witnesses (JW) includes more than 1.3 million followers in Brazil, being the third largest JW community in the world, after the United States and Mexico, representing approximately 0.5% of the Brazilian population².

The medical class faces ethical and legal challenges in the treatment of these patients, since this group refuses to receive blood transfusion or its components, often meeting with a medical duty to save lives. This ethical and legal dilemma causes many medical teams to refuse to perform surgical procedures in JW patients⁴.

Large operations, such as cardiovascular, thoracic, abdominal and organ transplants, have been performed in JW in a timid manner, with few citations in the literature. The principle of bloodless surgery, originally designed to rationalize the use of blood transfusions, was subsequently successfully applied to this population group, thanks to the advent of faster, more precise sealants, haemostatic agents and surgical techniques⁴.

NTRODUCTION

Suicide is among the top ten causes of death in all age groups and with higher incidence between 15 and 35 years. Its incidence is increasing in young population⁷.

According to the World Health Organization, various stress conditions can increase the risk of suicide¹. Eighty-five percent of patients who ingest foreign body have previous psychiatric illness and 84% of these patients have had previous intakes⁵.

From ingested foreign bodies 90% pass spontaneously through the gastrointestinal tract; 10-20% requires endoscopic removal; and 1% surgical approach⁶. In the general population, the foreign bodies are more often accidentally ingested such as bones, thorns or fruit stones. Most are housed in the physiological constrictions of the esophagus or abnormal narrowing sites (stenosis, rings or malignant tumors).

Here is presented one case of self-extermination attempt with continuous intake of nails in the course of a year.

CASE REPORT

Teenager of 16 year old was admitted with nails intake history during one year claiming attempt to self-extermination after constant arguments with his father and continuous nails intake. The parents were scavengers and had woodwork in which the patient had free access to the ingested material. Two days of admission he had epigastric pain, vomiting, and an episode of blackened stools. Physical examination showed good general condition, no collaborative, pallid (1+ / 4+), emaciated, heart beat 105 bpm, blood pressure of 120x80 mmHg, flat and flaccid abdomen, painful to deep palpation of epigastrium and no sudden pain to decompression. A large number of nails in the left iliac fossa was seen in abdominal radiograph (Figure 1); blood count was with leukocytosis and left shift.

INTRODUCTION

Schwannoma is a benign, neurogenic, slow-growing neoplasia, originated from Schwann cells, which are responsible by the myeline sheath on the peripheral nerves. This type of tumor is found more frequently on the central and peripheral nervous system and rarely occurs on the gastrointestinal tract¹^,²^,⁴^,⁵^,⁶^,⁸^,¹⁰. Along with leiomyoma, leiomyossarcoma, gastrointestinal stromal tumor (GIST) and others, it makes part of the mesenchymal gastrointestinal tumors group²^,⁵^,⁶^,¹⁰.

CASE REPORT

Female, 74 years old, presented on the emergency room with a chief complaint of abdominal pain, nauseas, vomiting, prostration and dizziness with one week of evolution. She reported past history of diverticulitis and denied weight loss, hematoquezia or previous abdominal surgeries. During the physical examination, she complained of pain on deep upper abdominal palpation, although no abnormal mass could be detected. Proctologic examination and laboratory exams showed no abnormalities.

Abdominal ultrassonography showed a nodular solid heterogenic type image on the left flank, with 6.1x5.6x4.3 cm. Investigation with contrasted computed tomography detected an delimited intramural lesion on the transverse colon, without invasion of surrounding organs (Figure 1).

INTRODUCTION

Dysontogenetic cysts, commonly referred as dermoid cysts or teratoid cysts, are hamartomas which may contain various derivatives of endoderm, mesoderm and ectoderm⁷. The majority of cases is reported in the midline of the body and especially in testes and ovaries. The most common site in the head and neck region is the lateral eyebrow, the so-called angular dermoid, and approximately 6.5% of the cases occur in the oral cavity. The teratoid cyst of the floor of the mouth is distinctly uncommon, with only a few cases reported, usually in the anterior portion⁸^,¹⁴.

Three theories with regard to the origin of cysts in the floor of the mouth were found in literature. According to the 1^st and most prevalent theory, these cysts originate from embryonic cells of the 1^st and 2^nd branchial arches during the 3^rd/4^th week of embryonic life. The 2^nd theory explains the pathogenic mechanism of the acquired form, which may be due to the implantation of epithelial cells subsequent to accidental or surgical injury (traumatic causes, iatrogenic antecedents, or an occlusion of a sebaceous gland duct). Lastly, the 3^rd theory maintains that these cysts are considered a variation of the cyst of the thyroglossal pore⁶. With regard to the etiology of dermoid and teratoid cysts in this site, there is much theory, but the most accepted is a possible sequestration of ectodermal tissue in the midline at the time of fusion of the first (mandibular) and second (hyoid) brachial arches²^,¹⁰.

Histologically, the dermoid cyst differs from epidermoid cyst only in the presence of normal or dysmorphic adnexal appendages within its walls, usually sebaceous glands or abortive hair follicles. The teratoid cyst is considered if the cyst wall contains other elements, such as muscle or bone¹¹. Surgical approaches for excision have been the treatment of choice for dermoid or teratoid cyst, including intraoral and extraoral skin incisions¹². Most of the authors recommend conservative surgical removal, trying not to rupture the cyst, as the luminal contents may act as irritants to fibrovascular tissues, producing postoperative inflammation. Recurrence and malignant transformation of oral cysts are unlikely after treatment⁸^,⁹.

This paper presents a case of teratoid cyst in a child with emphasis on the management and follow-up of six months.

INTRODUCTION

Teratomas are composed of somatic cells from two or more germ layers (ectoderm, mesoderm or endoderm)⁸. Although the child's age being the most affected, in adults it occurs at different locations, such as mediastinum, sacrococcix, retroperitoneum and more often in the gonads⁷^,¹³. Retroperitoneal teratomas in adults are rare, representing only 1-11% of all primary tumors in that anatomic region⁹, generally are benign and asymptomatic in the first stages. However when symptoms occur, they are typically due to their size, presenting with abdominal distension and a palpable mass¹². Diagnosis can be made by ultrasound, that can identify solid or cystic components, computerized tomography and magnetic resonance imaging, which are both superior than ultrasound to evaluate tumoral extention and relation to adjacent organs²^,⁴^,⁵^,¹²^,¹³. Angiography can be used to detect and evaluate the blood supply. In this article, it is presented a case of a giant retroperitoneal treated with surgical resection.

CASE REPORT

A 42-year-old male was suffering from an insidious abdominal distention for the last 13 years, that was more remarkable in the initial three years. There was no fever, abdominal pain, or bowel complaints. He denied smoking or drinking abuse. There was not any kind of disease in patient's past or family medical history. He had been treated with spironolactone years before, with no previous investigation, and it was suspended by the occurrence of gynecomastia. On admission, he was clinically in good condition, and presenting an important abdominal distention without tenderness, and bowel sounds preserved. The rest of the examination was unremarkable. Admission laboratory tests showed no abnormalities. An abdominal computerized tomography revealed a mass occupying all regions in the abdominal cavity, showing no apparent origin. The patient underwent exploratory laparotomy that showed a mass weighing approximately 30 kilograms (Figure 1), whose origin was in the retroperitoneum completely displacing the left kidney to the right iliac fossa. The patient did well post-operatively and is currently assymptomatic and has been followed as an outpatient. Histopathological analisys demonstrated heterogeneous contents, with predominant cystic formations and other unctuous and soft components, and the diagnosis of mature teratoma was confirmed by microscopy (Figure 2).