Epigastric pain: incarceration or rotation?

Introduction: Acute intrathoracic gastric volvulus occurs when the stomach has a twist mesenteroaxial/organoaxial or chest cavity resulting in a dilatation or rupture of the diaphragmatic hiatus or diaphragmatic hernia. The purpose of this work is to show a interesting case of gastric volvulus in a patient with several comorbidities. Case Report: A 77-year-old female with past history of hiatal hernia and mental disease associated with diabetes and atrial fibrillation. Patient went to the emergency department due to vomiting associated with blood. Analytical parameters (WBC, HGB, PCR, metabolic panel and liver function), showed no significant alterations. Thoracic X-ray revealed an enlarged mediastinum due to herniation of the stomach. A computed tomography (CT) scan confirmed intrathoracic localization of the gastric antrum with twist. Patient’s symptoms were relieved by nasogastric intubation and analgesia. After six months, the patient is still asymptomatic. Conclusion: In general, the treatment of an acute gastric volvulus requires an emergent surgical repair. In patients who are not surgical candidates (with comorbidities or an inability to tolerate anesthesia), endoscopic reduction should be attempted. Chronic gastric volvulus may be treated non-emergently, and surgical treatment is increasingly being performed using a laparoscopic approach. In this case, it is a chronic form that was solved with the placement of the nasogastric tube. A nasogastric decompression is an option in the chronic form of hiatal hernia associated to gastric volvulus in patients with serious comorbidities.

Correção laparoscópica de hérnia diafragmática traumática crônica

Diaphragmatic hernia secondary to blunt or penetrating trauma is rarely by itself a fatal event. However, if unpercieved, it may lead to severe complications caused by herniation of abdominal contents to the ethorax. Blunt trauma related to car accidents is the most frequent cause of diaphragmatic hernias. Associated injuries are frequently observed, provoked by severe traumas of great impact. These blunt trauma hernias occur mainly on the left side due to abdominal anatomy, since the liver is usually located on the right side. When injuries are observed on the right they tend to be more severe, generally related to major trauma of solid organs. Less frequently diaphragmatic hernias may be bilateral. The management of diaphragmatic injury would appear to be a simple matter of suturing the defect. However, peroperative diagnosis can be difficult and even at the time of surgery some diaphragmatic injuries can be overlooked if carefull exploration is not done. Associated injuries tend to divert attention from the diaphragmatic injury. Laparoscopic diagnosis and repair have been described with successfull. Laparotomy or thoracotomy can be employed for surgical repair of traumatic diaphragmatic hernias. Standard (laboratory/imaging) examinations may fail to make the diagnosis. Recently, the laparoscopic approach has proved useful for more precise evaluation of such injuries, very often allowing immediate repair of these lesions.

Hérnia diafragmática traumática crônica e fístula gastropleurocutânea

Traumatic diaphragmatic hernia is defined as a laceration of the diaphragm with an abdominal viscera herniation into the thorax. It is usually asymptomatic, with the exception of the cases with obstruction, strangulation, necrosis or perforation of the herniaded viscera. It is classified as acute, latent or chronic, in accordance with the evolutive period. At the latent phase, symptoms are indefinite and the radiological signals, which are suggestive of thoracic affections, are frequent and can induce a diagnosis error, leading to inadequate treatment.This article presents a case of chronic traumatic diaphragmatic hernia which was complicated by a gastricpleuralcutaneous fistula, due to an inadequate thoracic drainage. Considering that this is a chronic affection with an unquestionable surgical indication, due to the complications risk, it is essential to have a detailed diagnostic investigation, which aims at both avoiding an intempestive or inadequate therapeutics behaviour and reducing the affection morbimortality. Recently, the videolaparoscopic approach has proved to be more precise when compared to the other diagnostic methods, by direct visualization of the diaphragmatic laceration, allowing its correction by an immediate suture.

Hérnia diafragmática traumática

Traumatic diaphragmatic hernia is an uncommon but important problem in the patient with multiple injuries. Since diaphragmatic injuries are difficult to diagnose, those that are missed may present with latent symptoms of bowel obstruction and strangulation. The same may occur in the patients with stab wounds to the lower chest. Traumatic diaphragmatic hernia should be suspected on the basis of an abnormal chest radiograph in the trauma victim with multiple injuries. This article discuss about history, epidemiology, clinical signs and symptoms, diagnostic modalities, treatment and complications.

Hérnia de Morgagni simulando lipoma torácico

The Morgagni hernia is the rarest kind of diaphragmatic hernia , occurring in 3% of all cases. It consists of the protrusion of the abdominal content into the thoracic cavity including omentum and transverse colon, among others. It is more common in the right side and appears more frequently after 40 years of age or after a raise in the intra-abdominal pressure. Patients with Morgagni hernia are usually asymptomatic. In the X-ray it appears like an opaque image in the cardiophrenic angle.Surgical correction is the treatment of choice for this conditions. We present one case of Morgagni hernia successfully treated.

The possible role of selenium status in adverse pregnancy outcomes

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Concentrações plasmáticas e peritoneal da proteína de fase aguda HMGB1 em bezerros portadores ou não de hérnias umbilicais

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Risultati funzionali a lungo termine dopo sutura o plicatura del diaframma

Obbiettivo. Analizzare la funzionalità polmonare e diaframmatica dopo interventi di plicatura del diaframma con rete di rinforzo peri-costale eseguiti per relaxatio e riparazione di ernia transdiaframmatica cronica mediante riduzione e sutura diretta. Metodi. Dal 1996 al 2010, 10 pazienti con relaxatio unilaterale del diaframma e 6 pazienti con ernia transdiaframmatica cronica misconosciuta sono stati sottoposti a chirurgia elettiva. Gli accertamenti preoperatori e al follow-up di 12 mesi includevano prove di funzionalità respiratoria, misura della pressione massimale inspiratoria alla bocca in clino e ortostatismo, emogasanlisi, TC del torace e dispnea score. Risultati. I pazienti dei due gruppi non differivano in termini di funzionalità respiratoria preoperatoria nè di complicanze postoperatorie; al follow-up a 12 mesi il gruppo Eventrazione mostrava un significativo aumento del FEV1% (+18,2 – p<0.001), FVC% (+12,8 – p<0.001), DLCO% (+6,84 – p=0,04) e pO2 (+9,8 mmHg – p<0.001). Al contrario nrl gruppo Ernia solo il miglioramento della pO2 era significativo (+8.3 – p=0.04). Sebbene la massima pressione inspiratoria (PImax) fosse aumentata in entrambi i gruppi al follow-up, i pazienti operati per ernia mostravano un miglioramento limitato con persistente caduta significativa della PImax dall’ortostatismo al clinostatismo (p<0.001). Il Transitional dyspnoea score è stato concordante con tali miglioramenti pur senza differenze significative tra i due gruppi. La TC del torace ha evidenziato una sopraelevazione dell’emidiaframma suturato, senza recidiva di ernia, mentre i pazienti sottoposti a plicatura hanno mantenuto l’ipercorrezione. Conclusioni. L’utilizzo di un rinforzo protesico è sicuro e sembra assicurare risultati funzionali migliori a distanza in termini di flussi respiratori e di movimento paradosso del diaframma (valutato mediante PImax). Lacerazioni estese del diaframma coinvolgenti le branche principali di suddivisione del nervo frenico si associano verosimilmente a una relaxatio che può quindi ridurre il guadagno funzionale a lungo termine se non adeguatamente trattata mediante l’utilizzo di un rinforzo protesico.

Techniques for assessing cardiac output and fetal cardiac function

Fetal echocardiography was initially used to diagnose structural heart disease, but recent interest has focused on functional assessment. Effects of extracardiac conditions on the cardiac function such as volume overload (in the recipient in twin-twin transfusion syndrome), a hyperdynamic circulation (arterio-venous malformation), cardiac compression (diaphragmatic hernia, lung tumours) and increased placental resistance (intrauterine growth restriction and placental insufficiency) can be studied by ultrasound and may guide decisions for intervention or delivery. A variety of functional tests can be used, but there is no single clinical standard. For some specific conditions, however, certain tests have shown diagnostic value.

Bloodstream infections in pediatric ECLS: usefulness of daily blood culture monitoring and predictive value of biological markers. The British Columbia experience

INTRODUCTION: The incidence of bloodstream infection (BSI) in extracorporeal life support (ECLS) is reported between 0.9 and 19.5%. In January 2006, the Extracorporeal Life Support Organization (ELSO) reported an overall incidence of 8.78% distributed as follows: respiratory: 6.5% (neonatal), 20.8% (pediatric); cardiac: 8.2% (neonatal) and 12.6% (pediatric). METHOD: At BC Children's Hospital (BCCH) daily surveillance blood cultures (BC) are performed and antibiotic prophylaxis is not routinely recommended. Positive BC (BC+) were reviewed, including resistance profiles, collection time of BC+, time to positivity and mortality. White blood cell count, absolute neutrophile count, immature/total ratio, platelet count, fibrinogen and lactate were analyzed 48, 24 and 0 h prior to BSI. A univariate linear regression analysis was performed. RESULTS: From 1999 to 2005, 89 patients underwent ECLS. After exclusion, 84 patients were reviewed. The attack rate was 22.6% (19 BSI) and 13.1% after exclusion of coagulase-negative staphylococci (n = 8). BSI patients were significantly longer on ECLS (157 h) compared to the no-BSI group (127 h, 95% CI: 106-148). Six BSI patients died on ECLS (35%; 4 congenital diaphragmatic hernias, 1 hypoplastic left heart syndrome and 1 after a tetralogy repair). BCCH survival on ECLS was 71 and 58% at discharge, which is comparable to previous reports. No patient died primarily because of BSI. No BSI predictor was identified, although lactate may show a decreasing trend before BSI (P = 0.102). CONCLUSION: Compared with ELSO, the studied BSI incidence was higher with a comparable mortality. We speculate that our BSI rate is explained by underreporting of "contaminants" in the literature, the use of broad-spectrum antibiotic prophylaxis and a higher yield with daily monitoring BC. We support daily surveillance blood cultures as an alternative to antibiotic prophylaxis in the management of patients on ECLS.

Postoperative sepsis in infants below 6 months of age

BACKGROUND: Sepsis is a threatening postoperative complication especially in small infants. Regarding the advances in perinatal medicine, its incidence is unknown to date. We aimed to investigate the incidence, risk factors, laboratory findings and outcome of postoperative sepsis in infants younger than 6 months old. METHODS: We examined postoperative sepsis in babies below 6 months of age during a 4-year period at a tertiary pediatric institution. RESULTS: The rate of postoperative sepsis was 6.9%. Laparotomy with enterotomy, thoracotomy and diaphragmatic hernia repair (P<0.05, respectively) as well as low postnatal age and long operation time (P<0.001, respectively) were correlated with the incidence of sepsis. Significant independent predictors for the development of sepsis were the presence of a central venous catheter and perioperative antibiotic treatment (P<0.001, respectively). Coagulase negative Staphylococci were the major infecting organism associated with postoperative sepsis, accounting for 53% of monomicrobial infections. Complete blood counts with differential were not different between infants with sepsis and controls, who had undergone the same surgical procedures. Outcome was favorable in all cases; however, the length of hospital stay was significantly longer in sepsis patients (P<0.05). CONCLUSIONS: Postoperative sepsis syndrome is a frequent complication in infants below 6 months of age and causes significant prolongation of hospital stay. Adequate prevention and therapeutic strategies warrant further prospective investigations.

Aseptic intussuscepted incidental appendectomy: three successful cases

BACKGROUND: Incidental appendectomy remains a controversial issue. We aimed to collect experience using a modified surgical technique that could be applied securely in infants. METHODS: We performed aseptic intussuscepted incidental appendectomy (AIIA) in three patients using a technique that is thought to assure appendix necrosis along with intact cecal wall. RESULTS: There was no perioperative morbidity due to AIIA in the three patients. In two infants the necrotic appendix was found in the diaper. One infant died secondary to diaphragmatic hernia. Autopsy with histological examination revealed that the cecum was intact along with appendix necrosis. CONCLUSIONS: Modified AIIA could securely be performed in the 3 reported cases. We advocate prospective evaluation of the method.

A national case-control study of Ewing's sarcoma family of tumours in Australia

Limited population-based epidemiologic information is available on Ewing's sarcoma family of tumours (ESFT), a rare group of neoplasms. Several associations have been noted on a few studies but results were not consistent, except for exposure to farming among cases and their parents. Here we present the non-farm findings of a nationwide case-control study of ESFT in children and young adults in Australia. The analysis included 106 persons with confirmed ESFT and 344 population-based controls selected randomly via telephone. Information was collected by interview (84% face to face). We found a strong and significant association of ESFT with hernias, in particular hernia repaired in hospital (OR = 5.6, 95% Cl 1.3-6.4). Among other factors, there was a near doubling of risk for males, and male cases had their pubertal signs earlier (started shaving earlier) than male controls. There was also an increased risk of ESFT at higher levels of self-assessed exercise, but no other factor really stood out. For pregnancy-related factors, there was a tripling of risk for glandular fever, a doubling of risk for urinary tract infection and a near doubling of risk for X-rays during or just before pregnancy, but these estimates were not significant. In addition, there was a large number of inverse associations with medical conditions (specifically bone disorders), case exposure to medications, vaccinations and X-rays, with ultrasound during the pregnancy having the most certain effects. We conclude that, although the aetiology of ESFT remains obscure, overall there is strong evidence of an association with inguinal hernia; this can now be added to the farm-associated risk reported by others and us. The other associations reported here await replication and refinement in future studies. (C) 2003 Wiley-Liss, Inc.

Adattamento morfologico e variazione dell'espressione genica dopo pneumonectomia: osservazioni su modello sperimentale animale

Introduzione La pneumonectomia su modello animale potrebbe essere un’utile piattaforma di studio per approfondire i meccanismi della risposta compensatoria al danno polmonare. Scopo dello studio è determinare la presenza di variazioni morfologiche e di espressione del trascrittoma dopo pneumonectomia. Materiali e metodi Undici suini sono stati sottoposti a pneumonectomia sinistra. Sono stati eseguiti prelievi sito-specifici intraoperatori su polmone sinistro e successivamente confrontati con prelievi sito-specifici su polmone destro dopo eutanasia a 60 giorni. I prelievi degli animali con decorso regolare sono stati sottoposti a RNA-sequencing e successiva analisi computazionale per valutare il peso funzionale del singolo gene o di clusters di geni. Risultati Un animale è stato escluso per insorgenza di ernia diaframmatica. In 7/10 è stata riscontrata apertura della pleura mediastinica con parziale erniazione del polmone controlaterale e shift mediastinico. L’istologia ha mostrato dilatazione degli spazi aerei, rottura dei setti interalveolari, lieve infiammazione, assenza di fibrosi, stiramento radiale dei bronchi e riduzione del letto capillare. L’analisi di bulk RNA-sequencing ha identificato 553 geni espressi in modo differenziale (DEG)(P<0,001) tra pre e post-pneumonectomia. I primi 10 DEG up-regolati: Edn1, Areg, Havcr2, Gadd45g, Depp1, Cldn4, Atf3, Myc, Gadd45b, Socs3; i primi 10 geni down-regolati: Obscn, Cdkn2b, ENSSSCG00000015738, Prrt2, Amer1, Flrt3, Efnb2, Tox3, Znf793, Znf365. Tra i DEG è stata riscontrata una predominanza di geni specifici dei macrofagi. L’analisi di gene ontology basata su DAVID ha mostrato un significativo arricchimento della "via di segnalazione apoptotica estrinseca"(FDR q=7,60x10 -3), della via di “Risposta all’insulina”(FDR q=7,60x10 -3) ed un arricchimento di geni “Regolatori negativi del segnale DDX58/IFIH1”(FDR q=7.50x10 -4). Conclusioni Il presente studio conferma la presenza di variazioni macroscopiche e microscopiche fenotipiche dopo pneumonectomia. L’RNA sequencing e lo studio di genomica traslazionale hanno mostrato l’esistenza di geni singoli e di network di geni disregolati dopo pneumonectomia, prevalentemente in determinate popolazioni cellulari.

Hérnia de bochdalek em adulto

Bochdalek´s hernia is a congenital malformation of the posterolateral diaphragm region. It is more common on the left and more frequently seen in newborns and rare in adults, with over a few 100 reported cases. We present a case of Bochdalek´s hernia in a 49-year-old patient with long term dyspeptic symptoms. The upper endoscopy showed a gastric fundus herniation sliding into the chest through the diaphragmatic defect. The patient also presented with a rare pulmonary malformation diagnosed during surgery. It was corrected through thoracic approach with no other complications.