Noelia Ibañez

Hemoperitoneo tras estallido vesicular diferido como consecuencia de traumatismo abdominal

Las lesiones aisladas de vesı́cula biliar aparecen ú nicamente en un 2% de los traumatismos abdominales y se asocian a factores de riesgo como la cirrosis hepática. Presentamos el caso de un varón de 53 años con antecedentes de trastorno depresivo mayor con abuso y dependencia severa de alcohol, que acude por dolor abdominal de 6 dı́as de evolución tras una caı́da accidental contra la acera estando ebrio. A la exploración fı́sica destaca: tensión arterial de 152/90 y frecuencia cardiaca de 120 lpm, y a la palpación: distensión abdominal, hepatomegalia, defensa e irritación peritoneal. La analı́tica objetiva 7,5 g/dl de hemoglobina, 528 10/ml plaquetas, proteı́na C reactiva de 6,9 mg/dl y una actividad de protrombina del 90%. En cuanto al perfil hepático destaca una bilirrubina total de 2,3 mg/dl, GPT 91 U/l, GOT 38 U/l y GGT 416 U/l. La tomografı́a muestra una vesı́cula colapsada con material denso peri e intravesicular y discontinuidad en su región más caudal asociada a moderada cantidad de lı́quido libre intraperitoneal de densidad intermedia compatible con hemoperitoneo (fig. 1). La exploración quirú rgica del abdomen se realizó mediante laparoscopia objetivando perforación y avulsión parcial del fundus vesicular asociado a moderado cole-hemoperitoneo (fig. 2). Se realizó la colecistectomı́a laparoscópica y el lavado de la cavidad abdominal y el paciente fue alta sin incidencias a las 24 h. La anatomı́a patológica informó de colecistitis crónica inespecı́fica con focos de actividad aguda y perforación transmural. c i r e s p . 2 0 1 8 ; 9 6 ( 8 ) : 5 1 4Isolated gallbladder injuries appear in only 2% of abdominal trauma cases and are associated with risk factors such as liver cirrhosis. We present the case of a 53-year-old man with a history of major depressive disorder as well as severe alcohol abuse and dependence, who presented with abdominal pain for 6 days after an accidental fall against a sidewalk while intoxicated. Physical examination demonstrated: blood pressure 152/90 and heart rate 120 bpm; palpated abdominal distension, hepatomegaly, guarding and peritoneal irritation. Lab work-up showed: 7.5 g/dL of hemoglobin, 528 10/ml platelets, C-reactive protein 6.9 mg/dL and prothrombin activity 90%. Liver profile reported: total bilirubin 2.3 mg/dL, GPT 91 U/L, GOT 38 U/L and GGT 416 U/L. Tomography showed a collapsed gallbladder with dense periand intravesical material and discontinuity in the most caudal region, associated with a moderate amount of intraperitoneal free fluid of intermediate density compatible with hemoperitoneum (Fig. 1). Surgical exploration of the abdomen was conducted laparoscopically, revealing perforation and partial avulsion of the gallbladder fundus, associated with moderate chole-hemoperitoneum (Fig. 2). Laparoscopic cholecystectomy and lavage of the abdominal cavity were carried out, and the patient was discharged without incident 24 h later. The pathology study reported nonspecific chronic cholecystitis with foci of acute activity and transmural perforation. c i r e s p . 2 0 1 8 ; 9 6 ( 8 ) : 5 1 4

Right-colon mucinous adenocarcinoma mimicking a hydatid cyst

Hydatid disease is a fecal-oral transmission zoonosis which is endemically distributed among Mediterranean countries such as Morocco. It usually presents asymptomatically and a diagnosis is made due to cyst complications. It is most frequently located in the liver and lungs and forms large masses. The incidence of colon cancer has increased amongst population under 50 years of age during the last few decades. It has been proposed that young adult cases may have histological characteristics with a more aggressive clinical behavior. These patients are frequently diagnosed in advanced stages and a mucinous histology is frequently detected. Diagnosis is usually delayed due to a low clinical suspicion and the attribution of symptoms to other diseases such as irritable bowel and parasitosis, among others.

Reintervención tras complicaciones en cirugía laparoscópica colorrectal: ¿Aporta ventajas el abordaje laparoscópico?

INTRODUCTION The laparoscopic approach in colorectal complications is controversial because of its difficulty. However, it has been proven that it can provide advantages over open surgery. The aim of this study is to compare laparoscopic approach in reoperations for complications after colorectal surgery with the open approach taking into account the severity of the patient prior to reoperation. METHODS Patients who underwent laparoscopic colorectal surgery from January 2006 to December 2015 were retrospectively reviewed. Patients requiring urgent surgical procedures for complications in the postoperative period were divided in two groups: laparoscopic surgery (LS) and open surgery (OS). To control clinical severity prior to reoperation, The Mannheim Peritonitis Index (MPI) was calculated. RESULTS A total of 763 patients were studied, 40 required urgent surgery (24 OS/16 LS). More ileostomies were performed in the LS group (68.7% vs. 29.2%) and more colostomies in the OS group (37.5% vs. 6.2%), p<0.05. MPI was higher in OS group (27.31±6.47 [19-35] vs. 18.36±7.16 [11-24], p<0.001). Hospital stay after re-intervention, oral tolerance and surgical wound infection, were favorable in LS (p<0.05 in all cases). In patients with MPI score ≤26, laparoscopic approach showed shorter hospital stay after re-intervention, less stay in the critical care unit after re-intervention, earlier start of oral tolerance and less surgical wound infection (p<0.05). CONCLUSIONS A laparoscopic approach in re-intervention for complications after laparoscopic colorectal surgery associates a faster recovery reflected in a shorter hospital stay, earlier start of oral tolerance and a lower abdominal wall complication rate in patients with low severity index.

El colgajo V-Y como método de reparación de defectos perianales extensos

OBJECTIVES Some perianal pathologies require aggressive surgery that will need techniques to allow to re-establish the integrity of the perianal region. The purpose is to analyze short and long term results after perineal reconstruction with V-Y flaps. METHODS A retrospective review of prospectively collected database was conducted at Virgen de la Arrixacas Hospital in Murcia (España) between January 2000 and December 2013. The study includes all patients who underwent a perineal reconstruction with V-Y flaps. Demographic and surgical data and short-/long- term morbidity was recorded. RESULTS 10 patients were included, 6 males and 4 females. The average age was 58,1±17,4 years. Surgical indication included both malignant and benign pathologies. Operating time was 143,5±41,3min. R0 resection was performed in all cases although histopathological analysis showed involvement of the deeper margin in 3 cases. Length of hospital stay was 7,8±7,6 days. Regarding complications: 6 patients had partial dehiscence of the flap. None of the patients lost the flap completely. The most frequent late complication was anal stenosis (n=4). Follow up showed total continence in 7 patients. Two patients had variable fecal and/or flatus incontinence. A colostomy was made in one case due to severe incontinence. CONCLUSIONS V-Y flaps are an effective and feasible technique to cover large perianal defects after aggressive surgeries. However, this technique is not free of postoperative morbidity.