Íleo biliar: enterolitotomia videoassistida

Treatment, morbidity and mortality of patients with gallstone ileus depend on an accurate diagnosis made in time, and also on a more adequate therapeutic option.A detailed clinical evaluation is fundamental for such diagnosis. Complementary exams like a simple radiological study of the abdomen, high and low endoscopies, an ultrasonography, and a tomography can also be performed. The therapeutic options include the removal of the obstructive factor separately, the performance of a treatment in two separate stages, or the performance of a complete treatment (removal of the calculus, cholecystectomy, and the closing of the fistula).This study aims to present a case report of an elderly man of high surgical risk, presenting gallstone ileus. He was submitted to an isolated videoassisted enterolithotomy through a minilaparotomy. Taking into consideration the patient’s advanced age and the lack of evidence as to other biliary associated pathologies, the chosen treatment seemed to be a good alternative. The evolution was good, and after an 8 month follow-up the patient was found well and with no biliary symptoms whatsoever.

Síndrome de Zollinger-Ellison

The authors report a 49 years old, female patient who have been operated on several times (antrectomy with Billroth II reconstruction, partial gastrectomy with troncular vagotomy and total gastrectomy) in the last 5 years for recurrent ulcer disease. Three months ago, an abdomen ultra sound was done showing multiples images that suggested liver metastasis, which was confirmed by CT and RM. Two months ago, one new abdomen CT specifically to pancreas was done showing an expansive process in pancreas. Serial gastrine was 1532 pg/ml at the time (reference - until 115) and among clinical history and images exams Zollinger-Ellison Syndrome was suggested, a rare disease case.

Vesícula residual

Our objective is to report three patients with recurrent severe upper abdominal pain secondary to residual gallbladder. All patients had been subjected to cholecystectomy from 1 to 20 years before. The diagnosis was established after several episodes of severe upper abdominal pain by imaging exams: ultrasonography, tomography, or endoscopic retrograde cholangiography. Removal of the residual gallbladder led to complete resolution of symptoms. Partial removal of the gallbladder is a very rare cause of postcholecystectomy symptoms.

Divertículo do apêndice vermiforme

The authors present three cases report of appendicular diverticulum with associated diverticulitis, one of them asymptomatic. The clinical distinction between acute apendicitis and apendical diverticulitis is very difficult, the later usually with earlier suppuration. The are no consensus regarding preventive surgery for apendical diverticulitis. It is possible that incidence of apendicular diverticulum depends on careful anatomopathological exams.

Síndrome de Prune Belly

Prune Belly Syndrome is a fetal uropathy of unknown etiology with incidence of 1/35000 to 1/50000 alive been born, characterized by a classical triad: abdominal musculature congenital deficiency, bilateral criptorquidia and urinary tract malformations. The authors present a case of this rare pathology associated with a patent urachus. After complementary exams confirmed urinary tract alterations (bilateral ureterohidronefrosis and vesicoureteral reflux degree 5, besides urinary infection), the surgical approach was vesicostomy to decrease urinary infections and sepsis. Definitve surgery should be accomplished around the 12th month of life. Nowadays, the child is asymptomatic , with follow-up every two months, with return consultation bimonthly.

Síndrome da veia cava superior em criança

The authors describe a case of benign superior vena cava syndrome post phlebotomy in childhood, including exams for diagnosis and possible treatment.

Leiomiossarcoma do esôfago

The authors describe a case of esophageal leiomyosarcoma treated at the Abdominopelvic Surgery Department of the Brazilian National Cancer Institute, including literature review, addressing treatment and prognosis. A 45 year-old female patient complaining of dysphagia, with pre-operative exams sugestive of esophageal leiomyoma. She was submitted to an esophagusgastrectomy with digestive reconstitution using a gastric tube brought through the posterior mediastinum. The histopathological examination and immunohistochemical tests confirmed that the tumor was an esophageal leiomyosarcoma. She is at the 7th year of follow up with no recurrence nor digestive complains.

Leiomiossarcoma de veia cava inferior

We present a case of a 56-year-old woman with abdominal pain, normal laboratorial exams, normal carcinoembryonary antigen (CEA) and abdominal tomography exam with tumor formation in hepatic region. A tumor lesion was identified in a surgery in the medial segment of the inferior vena cava. A surgical resection was done, respecting the security limits, and reconstruction of the inferior vein with polytetrafluoroethylene (PTFE) graft was performed. The histological examination showed differentiated leiomyossarcoma of the inferior vena cava. This report points to the necessity of differential diagnoses with leiomyossarcoma in the presence of abdominal mass, supra-mesocolic, and non-specific abdominal symptoms, since its pre-surgical diagnoses occurs in only 5% to 10% of the cases.

Quimioterapia neoadjuvante torna ressecável carcinoma de cabeça de pâncreas

We present a case of non-resectable head pancreatic cancer by mesenteric venous invasion in which treatment with Gemcitabine (Gemzar) 1.000 mg/m 2 weekly for 3 weeks, followed by a 1-week rest, normalized CA 19.9 and promoted tumor resecability in a second operation (ultrasound, helicoidal tomography and magnetic ressonance exams). The value of the adjuvant treatment (radiochemotherapy) and the association with immunotherapy (Interferon) is discussed.

Pancreatite aguda sem etiologia aparente: a microlitíase deve ser pesquisada?

In a large number of patients, with episodes of acute pancreatitis the etiology is not identified, even after initial clinical history, detailed physical examination, laboratory tests and biochemical exams and an transabdominal ultrasound. This patient are considered with a unexplained acute pancreatitis. In this cases the treatment is restricted to improvement of symptoms. These patients after treated tend to have new episodes with the risk of raising the rates of morbidity and mortality. Therefore, the identification of a cause and its prompt treatment prevent at recurrent episodes of pancreatitis. This review aims to draw attention to how best diagnostic approach when the light of evidence-based medicine, to search for causes of difficult identification with microlithiasis, occult stones, the anatomical variations of biliary and pancreatic duct and in addition to sphincter of Oddi dysfunction.

Linfoma não-Hodgkin de cordão espermático

Non-Hodgkin´s lymphoma of the spermatic cord are rare. There is the registration of 14 (fourteen) cases of spermatic cord lymphoma in the literature, all treated with radical orchiectomy with or without radiotherapy. The adjuvant chemotherapy still is not a consensus, therefore the therapy must be individualized and applied according to the stage of the disease. The present study report a new case of primary non-Hodgkin´s lymphoma of the spermatic cord treated with radical orchiectomy through inguinal via with precocious ligature of the spermatic cord and adjuvant chemotherapy. Presently found with 2 and a half years of follow-up without recidivation clinical evidence, as the image exams show to be normal.

Hérnia intercostal transdiafragmática após fratura espontânea de costelas secundária à crise de tosse

One case of transdiafragmatic intercostal hernia after intense coughing fit followed by rib fractures in patient with history of pneumonia is presented. He had a severe coughing fit, developed a right toracoabdominal hematoma and then a tumor that was gradually enlarging. Image exams confirmed the diagnosis. Treatment consisted of surgical repair with the use of a polypropylene prosthetic mesh. It is a rare type of hernia. Only four cases were found in literature. The sooner the disease is diagnosed and treated the better the prognoses will be since it will prevent hernia from strangulation and incarceration.

Duodenopancreatectomia e hemicolectomia direita em monobloco para tratamento de câncer de cólon direito localmente avançado

This article reports the case of a patient whit a diagnosis of diarrhea and weight loss. Subsidiary exams showed ulcerovegetant lesion in the second duodenal portion and duodenocolic fistula. An exploratory laparotomy was performed and a neoplasic lesion in the hepatic angle of the colon was observed invading the second duodenal portion. The patient then underwent a cephalic gastroduodenopancreatectomy associated with en bloc right hemicolectomy and improved well in the postoperative period. Currently, 48 months after the surgery, he does not present any signs of the disease dissemination or recurrence. The consulted literature recommends that multivisceral resection must be considered if the patient is clinically able to undergo major surgery and does not present any signs of neoplasic dissemination, since the postoperative survival time is considerably longer in the resected group and some of these patients even achieve cure.

Síndrome de estenose pilórica por adenocarcinoma de piloro

We present a case of primary malignant pylorus neoplasia, emphasizing its rarity, the difficulty of diagnosis and the importance of an adequate prepare before the endoscopic procedure. Literature shows that tumors compromising the first, third and fourth segments of duodenum are rare, especially those of the pyloric area, representing only 0.35% of all malignant tumors of the gastrointestinal tract. Adenocarcinoma is the most common histological type, representing 50% of all malignant neoplasias at this site. The most common symptoms are weight loss, nausea, vomiting, abdominal pain, abdominal mass, sudden changes in intestinal habits and iron deficiency anemia secondary to chronic intestinal hemorrhage. Survival after five years is only 18%. We report a case of a seventy-one year-old male referring early satiety, epigastric pain, retrosternal burning and dyspepsia, with unspecific results in complementary exams, since complete gastric emptying was not achieved. As symptoms worsened, the patient was submitted to laparotomy, with identification of gastric dilation and severe pyloric stenosis, macroscopically suggesting malignancy. The chosen procedure was a subtotal gastrectomy. Adjuvant radiotherapy and chemotherapy were not used. The patient is been followed-up without tumor recurrence so far.

Jejunum and ileum blunt trauma: what has changed with the implementation of multislice computed tomography?

OBJECTIVE: to evaluate the impact of the new technology of multidetector computed tomography (MDCT) in improving the accuracy and early diagnosis of BSBI.METHODS: patients with blunt small bowel injuries (BSBI) grade> I were identified retrospectively and their CT scans reviewed by an experienced radiologist. Clinical and tomographic findings were analyzed and patients grouped as "pre-MDCT" and "post-MDCT", according to the time of implementation of a 64-slice MDCT.RESULTS: of the 26 patients with BSBI 16 had CT scans. Motor vehicle collision (62.5%) was the most frequent mechanism of injury. In the pre-MDCT period, five of the 13 patients (38.5%) had abdominal CT, and in the post-MDCT, 11 of 13 patients (84.6%) had the exam. During pre-MDCT, all CT scans were abnormal with findings of pneumoperitoneum (60%), free fluid (40%) and bowel wall enhancement (20%). In the post-MDCT group, all exams but one were abnormal and the most frequent findings were free fluid (90.9%), bowel wall enhancement (72.7%), and pneumoperitoneum (54.5%). However, the rate of delayed laparotomy did not change. The mortality rate in both groups were similar, with 20% during pre-MDCT and 18.2% during post-MDCT.CONCLUSION: the use of MDCT in abdominal trauma in our service has increased the sensibility of the diagnosis, but has had no impact on outcome so far.