José Luis Muñoz de Nova

Recidiva herniaria en forma de hernia de Amyand fistulizada

Introduccion: Se denomina hernia de Amyand a aquella hernia inguinal que contiene el apendice ileocecal en su interior. Caso clinico: Presentamos el caso de un varon de 72 anos que presenta un plastron inflamatorio de unos 10 cm de diametro en region inguinal derecha, con fistulizacion a piel sobre una placa necrotica en la zona central. En la tomografia computarizada abdominal se observa una hernia de Amyand complicada con perforacion del apendice y formacion de un absceso de 4x4x6 cm a nivel de la region inguinal. En la intervencion quirurgica urgente se realiza apendicectomia con lavado y desbridamiento del tejido celular subcutaneo, reparacion del defecto herniario mediante sutura directa, sin empleo de material protesico por la importante contaminacion local. Discusion: El termino hernia de Amyand fue descrito por primera vez por Claudius Amyand en 1735 al identificar una apendicitis aguda perforada en el interior de una hernia inguinal. En 2008 Losanoff y Basson proponen un sistema de clasificacion de la hernia de Amyand basandose en la constatacion durante la cirugia de la existencia o no apendicitis asociada y de su repercusion intraabdominal. El tratamiento quirurgico de este tipo de hernias es variable en funcion del tipo de hernia. El tratamiento quirurgico puede diferir de unos casos a otros segun los hallazgos intraoperatorios. La hernia de Amyand es una entidad infrecuente, cuyo diagnostico puede ser dificultoso debido a su baja incidencia, escasa sintomatologia y hallazgos ambiguos en pruebas de imagen y en la que la cirugia tiene un papel tanto diagnostico como terapeutico. El manejo quirurgico se basa en los hallazgos intraoperatorios que nos permiten diferenciar el tipo de hernia segun la clasificacion de Losanoff y Basson y llevar a cabo el tratamiento quirurgico adecuado.

Meckel's diverticulum in the adult: surgical treatment

Abstract Introduction: Management of asymptomatic Meckel’s diverticulum (MD) incidentally discovered in adults remains controversial. The aim of this study was to determine if incidental diverticula should be removed. Materials and methods: We reviewed a consecutive series of patients surgically managed from January 1994 to December 2016. Patients were divided into two groups according to symptomatic or asymptomatic diverticula, and characteristics were compared. Results: The study included 66 patients: 30 in the symptomatic group (45%) and 36 in the incidental group (55%). We found 12 females (18.2%), and the ratio male:female was higher in the symptomatic group (14:1 vs. 2.6:1). Patients in the symptomatic group were significantly younger: 41.7 ± 18.1 vs. 54.7 ± 19.8 years (p = .007). MD in the symptomatic group tended to be longer (3.8 ± 1.9 vs. 2.6 ± 0.9 cm; p = .003). A MD-associated malignancy was present in three patients (4.5%), all neuroendocrine tumours. Major postoperative complications occurred in 6.6% of symptomatic patients and 0% within the incidental group, without specific morbidity related to prophylactic surgery. No mortality was observed. Conclusion: Resection of incidentally found Meckel’s diverticulum can be made because of benefits outweigh the risks in this high-risk area for cancer.

Acute pancreatitis secondary to periampullary duodenal diverticulitis.

The patient is a 93-year-old woman with a history of recurrent acute cholecystitis and pancreatitis who came to the ER with epigastric abdominal pain radiating towards the back and nausea. Lab work showed normal inflammatory parameters, amylase 1261 U/L, and hepatic profile without alterations. Computed tomography scan demonstrated multiple duodenal diverticula and detected a periampullary diverticulum with signs of local inflammation pressing on the intrapancreatic common bile duct (Figs. 1 and 2). The extrahepatic bile duct showed no alterations, although the pancreas had mild atrophy and the Wirsung duct presented moderate dilatation. The patient was hospitalized and managed conservatively; her progress was favorable and she was discharged one week later.

Carcinomatosis peritoneal y vesícula de Courvoisier

A 72-year-old female patient who had undergone total gastrectomy 78 months earlier due to gastric adenocarcinoma T2N2M0 came to the emergency room with symptoms of pain in the right hypochondrium, nausea and decreased bowel transit. Upon examination, she presented a distended abdomen with multiple masses, especially a palpable, although not painful, gallbladder with notable cholestasis. A computed tomography scan showed peritoneal carcinomatosis with an implant at the angle of Treitz (Fig. 1A), which caused retrograde dilatation of the duodenum, main pancreatic duct, bile duct and gallbladder (Courvoisier sign) (Fig. 1B). Given these findings, it was decided to initiate palliative symptomatic treatment. c i r e s p . 2 0 1 6 ; 9 4 ( 3 ) : 1 7 9

Hidatidosis hepática gigante

Paciente varón de 83 años, con antecedentes de hipertensión arterial y hernia de hiato, acude a urgencias por presentar cuadro de febrı́cula y dolor abdominal. A la exploración destaca un efecto masa doloroso en hipocondrio derecho. Se realiza una colangiorresonancia magnética en la que se aprecian 2 quistes hidatı́dicos con mú ltiples vesı́culas en su interior, localizados en los segmentos VIII y entre los segmentos V y VI, que miden 12 11 cm y 19 12 cm, respectivamente (fig. 1). Se identifica una interrupción de la periquística con formación de vesı́culas adyacentes, que se extienden hacia el segmento IV. Diagnóstico: quiste hidatídico gigante. c i r e s p . 2 0 1 5 ; 9 3 ( 2 ) : e 1 1

Giant Hepatic Hydatidosis

Paciente varon de 83 anos, con antecedentes de hipertension arterial y hernia de hiato, acude a urgencias por presentar cuadro de febricula y dolor abdominal. A la exploracion destaca un efecto masa doloroso en hipocondrio derecho. Se realiza una colangiorresonancia magnetica en la que se aprecian 2 quistes hidatidicos con mu ltiples vesiculas en su interior, localizados en los segmentos VIII y entre los segmentos V y VI, que miden 12 11 cm y 19 12 cm, respectivamente (fig. 1). Se identifica una interrupcion de la periquistica con formacion de vesiculas adyacentes, que se extienden hacia el segmento IV. Diagnostico: quiste hidatidico gigante. c i r e s p . 2 0 1 5 ; 9 3 ( 2 ) : e 1 1

Signo del donut en el linfoma tiroideo

A 45-year-old woman, who was in follow-up due to multinodular goiter, presented symptoms of rapid growth in the size of the thyroid gland with associated dysphonia, dysphagia to liquids and dyspnea when lying down. Cervical CT revealed a large thyroid mass (12 13 8.5 cm) that displaced and compressed the pharynx and esophagus, with notable infiltration of the tracheal lumen (6 mm). The patient also presented with the ‘‘doughnut sign’’ as the mass completely wrapped around the trachea, separating it from the esophagus (Fig. 1), which is characteristic of thyroid lymphoma. Thyroid biopsy confirmed the diagnosis of diffuse large B-cell non-Hodgkin’s lymphoma. c i r e s p . 2 0 1 3 ; 9 1 ( 6 ) : e 3 1