María Pilar Guillén-Paredes

Adult intussusception: 14 case reports and their outcomes

AIMS: To analyze diagnostic and therapeutic options depending on the clinical symptoms, location, and lesions associated with intussusception, together with their follow-up and complications. PATIENTS AND METHODS: Patients admitted to the Morales Meseguer General University Hospital (Murcia) between January 1995 and January 2009, and diagnosed with intestinal invagination. Data related to demographic and clinical features, complementary explorations, presumptive diagnosis, treatment, follow-up, and complications were collected. RESULTS: There were 14 patients (7 males and 7 females; mean age: 41.9 years-range: 17-77) who presented with abdominal pain. The most reliable diagnostic technique was computed tomography (8 diagnoses from 10 CT scans). A preoperative diagnosis was established in 12 cases. Invaginations were ileocolic in 8 cases (the most common), enteric in 5, and colocolic in 2 (coexistence of 2 lesions in one patient). The etiology of these intussusceptions was idiopathic or secondary to a lesion acting as the lead point for invagination. Depending on the nature of this lead point, the cause of the enteric intussusceptions was benign in 3 cases and malignant in 2. Ileocolic invaginations were divided equally (4 benign and 4 malignant), and colocolic lesions were benign (2 cases). Conservative treatment was implemented for 4 patients and surgery for 10 (7 in emergency). Five right hemicolectomies, 3 small-bowel resections, 2 left hemicolectomies, and 1 ileocecal resection were performed. Surgical complications: 3 minor and 1 major (with malignant etiology and subsequent death). The lesion disappeared after 3 days to 6 weeks in patients with conservative management. Mean follow-up was 28.25 months (range: 5-72 months). CONCLUSIONS: A suitable imaging technique, preferably CT, is important for the diagnosis of intussusception. Surgery is usually necessary but we favor conservative treatment in selected cases.

Protective ileostomy: complications and mortality associated with its closure

INTRODUCTION diverting loop ileostomies are widely used in colorectal surgery to protect low rectal anastomoses. However, they may have various complications, among which are those associated with the subsequent stoma closure. The present study analyses our experience in a series of patients undergoing closure of loop ileostomies. METHOD retrospective study of all the patients undergoing ileostomy closure at our hospital between 2006-2010. There were 89 patients: 56 males (63%) and 33 females (37%) with a mean age of 55 (38-71) years. The most common indication for ileostomy was protection of a low rectal anastomosis, 81 patients (91%). The waiting time until stoma closure, type and frequency of the complications, length of hospital stay and mortality rate are analysed. RESULTS waiting time before surgery was 8 (1-25) months. Forty-one patients (45,9%) developed some type of complication, three were reoperated (3.37%) and one patient died (1.12%). The most important complications were intestinal obstruction (32.6%), diarrhoea(6%), surgical wound infection (6%), enterocutaneous fistula (4.5%), rectorrhagia (3.4%) and anastomotic leak (1.12%). The mean length of patient stay was 7.54 (2-23) days. CONCLUSIONS protective ostomies in low rectal anastomoses have proved to be the only preventive measure for reducing the morbidity and mortality rates for anastomotic leakage. However, creation means subsequent closure, which must not be considered a minor procedure but an operation with possibly significant complications, including death, as has been shown in publications on the subject and in our own series.

Schwannoma en colon descendente: presentación de una neoplasia en rara localización

Presentamos un varón de 67 años en el que la colonoscopia de cribado evidenció, a 35 cm del margen anal, una lesión polipoidea ulcerada. La biopsia fue inespecífica. La TC y la colonografía virtual mostraron una masa polipoidea en colon izquierdo de 4,5x3,6x3,7 cm con adenopatías regionales, sin metástasis a distancia. El paciente acudió a urgencias por rectorragia y dolor abdominal. La ecografía mostró una invaginación cólico-cólica originada por la masa polipoidea. Se intervino mediante laparotomía media objetivándose una invaginación en colon descendente, sin observar infiltración ni diseminación a distancia. Se realizó una colectomía segmentaria con anastomosis latero-lateral mecánica. El paciente evolucionó favorablemente. El estudio anatomopatológico informó de una tumoración blanco-amarillenta submucosa bien delimitada constituida por células fusiformes que formaban empalizadas, un infiltrado linfoide intratumoral con nódulos periféricos y escasa actividad mitótica. La inmunohistoquímica dio positividad para S-100 y CD68, no habiendo reactividad para CD117, CD34, actina y CD10 (Fig. 1). El diagnóstico definitivo fue de schwannoma de colon. En 3 años de seguimiento no se ha evidenciado recidiva.

Necrosis séptica de miembro inferior secundaria a picadura de araña reclusa parda

La picadura de araña reclusa parda (Loxosceles reclusa) es una entidad infrecuente en nuestro medio, pero es importante incluirla en el diagnóstico diferencial de una celulitis porque su evolución puede ser mortal. Presentamos un caso de necrosis séptica de miembro inferior secundaria a picadura de araña reclusa parda en nuestro medio. Varón de 43 años sin antecedentes de interés, que acude a urgencias por cuadro de dolor en pie derecho, junto con signos de Celso, tras picadura de arácnido en las 48 h previas, asociado a fiebre, náuseas, vómitos, artralgias, cefaleas y orina oscura. A la exploración fı́sica: 38 8C, orina colú rica, resto de constantes normales. Lesión papular en pliegue interdigital del 4.8 y 5.8 dedos del pie derecho asociada a una celulitis incipiente en el dorso del pie (fig. 1). Analı́tica: 29.720 leucocitos/ml (85% polimorfonucleares); PCR: 14,7; lactato: 1,1; CPK: 138; urea: 32; creatinina: 0,98; resto de parámetros normales. Radiografı́a de tórax normal. Eco-Doppler de miembros inferiores normal. Ingresa para tratamiento con antibioterapia (amoxicilina-clavulánico) y tratamiento local (miembro elevado, frı́o local, compresión). Pasadas 24 h, la celulitis progresa por cara anterior, para terminar rodeando por completo la pierna al 4.8 dı́a. Posteriormente, aparece una gran flictena que abarca el dorso del pie de unos 15 5 cm de superficie con una necrosis de piel y tejido celular subcutáneo, acompañado de una linfangitis (fig. 2). Se amplı́a el espectro con vancomicina, evolucionando analı́tica y clı́nicamente de forma lenta pero favorable, con disminución progresiva de la celulitis, siendo alta al 12.8 dı́a. En revisiones posteriores se encuentra asintomático, con fuerza y movilidad conservadas. La araña reclusa parda (Loxosceles reclusa) es una araña venenosa, también llamada araña del rincón o violinista, porque son fotofóbicas y su cabeza tiene forma de violı́n. Aunque se trata de una araña originariamente de Estados Unidos, parece que se ha adaptado a nuestro medio, como ha sucedido en Sevilla, donde se han dado varios casos de picaduras donde estuvo trabajando nuestro paciente.

Síndrome de Horner traumático sin lesión vascular

Treatment of penetrating trauma to the neck is complex due to the vital structures involved. Early diagnosis of cervical injuries is essential, as any delay could lead to elevated morbidity and mortality. We present a case of a penetrating cervical wound with Horner syndrome and no associated vascular injury. The patient is a 28-year-old male, with no prior medical history of interest, who was sent to our hospital after a suicide attempt with a sharp object (knife) to the neck. We observed dysphonia, but no dyspnoea. Upon examination, vital signs were normal, oxygen saturation was 100% and the Glasgow Coma Scale was 14 points. The patient had 5 injuries in cervical zone II (3 superficial right lateral incised wounds and 2 incised-contused wounds that surpassed the platysma on the left side) with crackles upon palpation on the left side. Anisocoria was observed with miosis of the left eye and ipsilateral ptosis (Fig. 1); the remaining examination was normal. Cervical and chest radiograph demonstrated subcutaneous emphysema without pneumothorax. CT angiography with oral contrast is shown in Fig. 2. Laryngoscopy revealed paralysis of the left vocal cord in a paramedian position together with paralysis of the left hypoglossal nerve; sharp force injury to the left pyriform sinus could not be ruled out. Conservative therapy was begun with intravenous antibiotics, nil per os and follow-up radiology study with a second cervical CT in 24 h, which demonstrated improvements in the patient’s condition, including reduced subcutaneous emphysema and pneumomediastinum. After progressively initiating oral tolerance, the patient progressed favourably with follow-up lab work and radiological studies within normal ranges. The patient was discharged on the 7th day after hospitalisation after psychiatric testing. At the one-year follow-up visit in the outpatient clinic, the patient continued to have Horner syndrome, but no longer presented paralysis of the vocal cord or of the left hypoglossal nerve. Essential treatment for patients with penetrating cervical wounds involves initial airway assessment and, afterwards, haemorrhage control. Once these two aspects are regulated and the patient is haemodynamically stable, the cervical lesions can be evaluated. The diagnostic method of choice in a stable patient is CT angiography, as it is not only a non-invasive method that can evaluate patients at risk for vascular injuries in the neck (pseudoaneurysms, arterial dissections, arteriovenous fistulas, vascular occlusions), but it is also able to diagnose injuries to the digestive tube, airway, spinal cord, etc. that may have gone unnoticed on initial examination. Furthermore, this selective treatment of cervical lesions should include an endoscopic study of the airway and an oesophagogram/ oesophagoscopy to exclude airway and oesophageal injuries. Our case was characterised by an uncommon clinical presentation: traumatic Horner syndrome. Horner syndrome is defined by the triad comprised of anisocoria (resulting from the miosis of the affected eye), ptosis and anhidrosis, which is caused by the loss of sympathetic innervation of the eye and ipsilateral face. c i r e s p . 2 0 1 5 ; 9 3 ( 1 0 ) : e 1 3 9 – e 1 4 1

Necrosis intestinal segmentaria en paciente joven

Segmental ischemic colitis is an uncommon disease in young patients, being usually associated to drug abuse, infectious or autoimmune diseases. We present a case that, in spite of a complete diagnostic study, had repeatedly two attacks of intestinal necrosis during his admission.

Solid pseudopapillary neoplasm of the pancreas or Frantz's tumour: Report of two cases with different locations

We report 2 cases in women aged 30 and 27 years, who are currently under follow-up. Both presented with non-specific clinical features such as epigastric pain, vomiting, diarrhoea, fever or weight loss over the previous months. Ultrasound disclosed heterogeneous masses in the tail and head of the pancreas, respectively. The study was completed in both women with computed tomography and magnetic resonance, which revealed heterogeneous lesions with solid and cystic components. They underwent surgery with a preoperative suspicion of SPTP: Distal splenopancreatectomy in the patient with the tumour in the tail of the pancreas and cephalic pancreatoduodenectomy with pylorus conservation in the woman with the tumour in the head of the pancreas. In both women, the pathological anatomy and immunohistochemistry, with positivity for CD10, CD56, vimentin, neuronal enolase and progesterone receptors, and mild positivity to chromogranin, established a final diagnosis of SPTP. SPTP occurs 90-95 % of the time in young women in their 3 decade of life (2) and has a preference for Asians (3). The most common location is the body and tail and on rare occasions it is found in the retroperitoneum, ectopic pancreatic tissue, mesentery or liver (4). Its growth is slow, which is why patients are asymptomatic (5) or have non-specific clinical features and why diagnosis is usually casual in 15 % of cases (6). Imaging tests are usually typical: well-delimited heterogeneous mass due to its haemorrhagic necrotic solid and cystic components (7). Fine-needle puncture-aspiration is controversial, as there is no clear efficiency for differential diagnosis and it may be confused with a pseudocyst when only necrotic material is collected. The origin of SPTP is still uncertain, although a theory gaining strength is that it originates in pluripotential pancreatic cells which would be favoured by genetic factors, and hormone stimuli due to a greater frequency in women and the presence of hormone receptors (8). Immunohistochemistry usually shows a positive reaction

Neumotórax bilateral tras la colocación de un drenaje pleural

pulmón explantado del receptor. El tratamiento del SEG incluyó soporte hemodinámico y respiratorio. Los corticoides, que el receptor recibió desde el primer dı́a del postoperatorio como parte del régimen de inmunodepresión, se utilizan en el tratamiento del SEG, pero no han demostrado ejercer un claro efecto beneficioso. De hecho, parecen tener un efecto paradójico, ya que se considera que desempeñan un papel en la génesis del SEG en pacientes en tratamiento crónico con corticoides.