Roberto de la Plaza Llamas

Neumomediastino y enfisema cervical como comienzo de dehiscencia de anastomosis colorrectal

The patient is an 83-year-old woman with Alzheimer’s who had been discharged 4 days earlier after a sigmoidectomy performed 11 days before due to sigmoid adenocarcinoma (pT3N0). She came to the hospital because of general malaise, cough and dyspnoea. Physical examination detected bilateral laterocervical subcutaneous emphysema. Work-up showed lactic acid 2.5 mmoL/L, neutrophils 12,860/mL and C-reactive protein 466.5 mg/L. A chest radiograph (Fig. 1) showed (from top to bottom) subcutaneous emphysema in the cervical region, pneumomediastinum and retropneumoperitoneum. Thoracoabdominal computed tomography (CT) with intravenous and endorectal contrast revealed, on the axial view (Fig. 2): retroperitoneal contrast (arrow), anastomotic dehiscence and adjacent extravasation of contrast (circle). The coronal slice demonstrated (Fig. 3): retropneumoperitoneum and extravasation of retroperitoneal contrast. The patient was treated surgically, at which time we found dehiscence of the colorectal anastomosis. Cultures were positive for Enterococcus, Bacteroides, Clostridium and Morganella morganii. Hartmann’s procedure was performed and a drain inserted. The patient was discharged 60 days later. c i r e s p . 2 0 1 5 ; 9 3 ( 8 ) : e 8 1

Pelvic Solitary Fibrous Tumor

Solitary fibrous tumor (SFT) is an extremely rare mesenchymal neoplasm, first described as hemangiopericytoma. It is divided into pleural and extrapleural forms, the latter being considered uncommon. We describe the case of a man who presented a pre-rectal SFT who underwent an embolization of the median sacral artery (MSA) and branches of internal iliac arteries (IIA) to facilitate surgery. A 69-year-old man with a history of type 2 diabetes mellitus, untreated due to difficult control of hypoglycemias, had suffered diaphoresis for 5 months and nocturnal hypoglycemias with increased abdomen size of 1 month’s duration. On physical examination, his blood pressure was 212/ 112 mmHg and his heart rate was 106 beats per minute. The abdomen was globulous and distended. In his laboratory data on admission were altered glucose (64 mg/dL) but C-peptide and proinsulin were normal. Ultrasound showed an enormous abdominal mass and the computerized tomography (CT) scan revealed a pelvic pre-rectal mass which caused a rectal and sigmoid colon displacement and vesical compression. The mass of 240 mm (crown-rump) × 132 mm (front-to-back) × 160 mm (transversal) was solid and lobulated, with an increase in vascularization. The central area showed hypoattenuation with necrosis and irregular calcifications (Fig. 1a, b). Colonoscopy revealed an extrinsic compression of the rectum and a core needle biopsy was performed, showing neoplasic fusiform cells positive for CD34, CD99, and bcl-2, and negative for desmin, actin, S100, and cytokeratins. On this basis, SFT was diagnosed. Subsequently, the patient was referred to the surgery department. Presurgical embolization was considered necessary. The MSA, branches of left IIA, and branches of the right IIA were embolized (Fig. 2a–b2). Skin necrosis developed in the left gluteal area (Fig. 3a). In the CT scan 11 days after the third procedure, the mass had decreased with an increase in the central necrosis area (Fig. 1c). The patient was submitted for bilateral retrograde ureteral catheterization and a complete en bloc resection, a low anterior resection with mechanical anastomosis, and a lateral colostomy were carried out with negative margins. Recovery was uneventful and the patient was discharged 9 days after surgery, without the ureteral catheters. The hypertension and hypoglycemias disappeared. The pathology revealed a SFT measuring 230 mm × 95 mm× 150 mm and weighing 1.9 kg (Fig. 3b, c). The rectum was not infiltrated microscopically. Our patient has now been followed for 12 months, without recurrence. SFT is a controversial entity. Its late diagnosis, due to the compression of other structures, may be associated with paraneoplastic syndromes, as in our case, and hypoglycemias and hypertension. En bloc resection is indicated and a previous embolization must be considered in order to make surgery possible. * Cristina García-Amador cristina_ga__@hotmail.com

Chylous Mesenteric Cyst

A 64-year-old woman presented with a history of rheumatic heart disease, hysterectomy and left-side adnexectomy, high blood pressure, and hepatitis C virus. Routine ultrasound for hepatitis C virus revealed an abdominal cystic mass. Computed tomography (CT) showed a cyst measuring 13 × 11 cm, with fat density displacing and imprinting small intestine loops, without liquid level (Fig. 1, arrows). The CT diagnosis was appendicular mucocele, mesenteric cyst, or (less probably) ovarian carcinoma. Abdominal examination identified a mass effect in the right lower abdomen. Laboratory results, including hepatic and lipid profiles, were normal. The laparotomy revealed a cystic tumor of milky aspect dependent on the intestinal mesentery with a maximum diameter of 12 cm (Fig. 2). A 9-cm bowel resection was performed, including the mass. Histological and immunohistochemical study showed a vascular cyst, with a smooth internal surface, and partitions producing a multilocular appearance. The intestinal lumen did not present lesions. The cyst affected the intestinal wall, the serosa, muscularis propia, and submucosa, but not the mucosa. The immunohistochemical study was positive for D240 (lymphatic vessel marker) and CD31. The endothelial marker CD34 and mesothelial markers (mesothelin, MOC-31, calretinin and WT-1) were negative. The lesion was thus compatible with cystic lymphangioma. Analysis of the content of the cyst revealed triglycerides 5586 mg/dl, glucose 74 mg/dl, amylase 17 UI/ml, and proteins 125 g/L. The final histological diagnosis was chylous mesenteric cyst. In the follow-up at 86 months, no alterations have been observed.

Letter to the Editor regarding “Does it have a negative economic impact the intraoperative parathyroid hormone assay in primary hyperparathyroidism?”

Dear Editor, We read with interest the retrospective study by Badii et al, who evaluated the usefulness of the intraoperative parathyroid hormone (IOPTH) assay and presented a cost-benefit analysis. This analysis was based exclusively on 2 parameters: the cost of measuring parathyroid hormone and the cost associated with the use of the operating theater. The authors affirm that the use of IOPTH substantially raises costs compared with nonuse and that “There is no doubt, however, about the considerable economic benefits of not using IOPTH except when absolutely necessary . . . including shorter operating time, which may have favorable effects on the patient and results in fewer complications, shorter anesthesia, and length of hospital stay. . .We reserve its use for reoperations for parathyroid pathology and after any re-cervicotomy.” We have several doubts about the methodology used in the study, which we outline here. A cost-benefit analysis requires an assessment of all the costs and all the benefits, something that this study has not done. Naturally, we respect the authors’ decision not to consider the social perspective in the economic evaluation. However, they did not consider the hospital perspective either, because they did not include basic economic costs, such as the length of hospital stay associated with the use or nonuse of IOPTH. Although the authors state that 1 of the benefits of using IOPTH is that it shortens hospital stay, they do not assess this variable. In addition, in this cost-benefit analysis, certain costs were attributed to group A, which were not a direct consequence of the use of IOPTH, and which should in any case have been considered as benefits: IOPTH detected the only 2 cases of recurrence of hyperparathyroidism in group A but the authors added the reoperation of 1 of the patients to the costs: “. . .Because IOPTH did not decrease after the removal of the first adenoma, bilateral exploration was performed but the surgeon failed to find another abnormal gland.” Nor does the study take into account the following aspects, which may have introduced a bias in the results regarding costs:

Carta científicaFístula pancreático-colónica espontánea en paciente con pancreatitis aguda graveSpontaneous pancreatic-colonic fistula in a patient with severe acute pancreatitis

The formation of fistulas from the pancreas to neighbouring organs as a complication of severe acute pancreatitis is well known, although rare.1 The most common such fistulas are pancreatic-colonic fistulas, which generally appear following pancreatic necrosectomy; it is very unusual for them to develop preoperatively.2,3 We present a case of severe acute pancreatitis with the complication of a spontaneous pancreatic-colonic fistula. A 77-year-old woman with a personal history of chronic renal failure (CRF), ischaemic heart disease, pacemaker and mechanical aortic valve was admitted for a first episode of severe acute pancreatitis of biliary origin (cholelithiasis without cholecystitis on ultrasound). Computed tomography (CT) scans were performed, without IV contrast, initially because of exacerbation of the CRF and then because of patient refusal. Signs of septic shock 48 hours after onset of symptoms were treated with piperacillin-tazobactam antibiotic. An urgent abdominal CT scan revealed blurring of the peripancreatic fat with no clear evidence of defined collections. On day 3, attempted endoscopic placement of a nasojejunal tube failed due to the presence of a duodenal stenosis with an inflamed appearance. Parenteral nutrition was started but was later complicated with bacteraemia caused by Staphylococcus epidermidis, for which vancomycin was added to the treatment. Owing to poor patient progress, another CT scan was performed 15 days later that showed 2 peripancreatic collections, one adjacent to the head and the other to the tail, measuring 50 × 37 mm and 63 × 57 mm, respectively (Fig. 1). Antibiotic cover and parenteral nutrition were maintained, with clinical and analytical improvement that continued after discontinuation of both. The patient was discharged 42 days after admission. Twenty-four hours after discharge, the patient attended the emergency department for low-grade fever, vomiting and abdominal pain that fulfilled criteria for sepsis of probable abdominal origin. Empirical treatment was started with meropenem and an abdominal CT scan with oral contrast and enema revealed a decrease in the size of the peripancreatic collection of the head, with gas inside, suggestive of fistulization to the gastrointestinal tract (Fig. 1B). A CT scan of the colon confirmed the existence of a pancreatic-colonic fistula (Fig. 2A). Conservative treatment was commenced with nil by mouth and levofloxacin-metronidazole. The fistula persisted despite clinical and analytical improvement. Leukocytosis and acute phase reactants reappeared when antibiotic therapy was discontinued after 2 weeks. Given the low rate of spontaneous resolution of this type of fistula, we performed

Fístula pancreático-colónica espontánea en paciente con pancreatitis aguda grave

The formation of fistulas from the pancreas to neighbouring organs as a complication of severe acute pancreatitis is well known, although rare.1 The most common such fistulas are pancreatic-colonic fistulas, which generally appear following pancreatic necrosectomy; it is very unusual for them to develop preoperatively.2,3 We present a case of severe acute pancreatitis with the complication of a spontaneous pancreatic-colonic fistula. A 77-year-old woman with a personal history of chronic renal failure (CRF), ischaemic heart disease, pacemaker and mechanical aortic valve was admitted for a first episode of severe acute pancreatitis of biliary origin (cholelithiasis without cholecystitis on ultrasound). Computed tomography (CT) scans were performed, without IV contrast, initially because of exacerbation of the CRF and then because of patient refusal. Signs of septic shock 48 hours after onset of symptoms were treated with piperacillin-tazobactam antibiotic. An urgent abdominal CT scan revealed blurring of the peripancreatic fat with no clear evidence of defined collections. On day 3, attempted endoscopic placement of a nasojejunal tube failed due to the presence of a duodenal stenosis with an inflamed appearance. Parenteral nutrition was started but was later complicated with bacteraemia caused by Staphylococcus epidermidis, for which vancomycin was added to the treatment. Owing to poor patient progress, another CT scan was performed 15 days later that showed 2 peripancreatic collections, one adjacent to the head and the other to the tail, measuring 50 × 37 mm and 63 × 57 mm, respectively (Fig. 1). Antibiotic cover and parenteral nutrition were maintained, with clinical and analytical improvement that continued after discontinuation of both. The patient was discharged 42 days after admission. Twenty-four hours after discharge, the patient attended the emergency department for low-grade fever, vomiting and abdominal pain that fulfilled criteria for sepsis of probable abdominal origin. Empirical treatment was started with meropenem and an abdominal CT scan with oral contrast and enema revealed a decrease in the size of the peripancreatic collection of the head, with gas inside, suggestive of fistulization to the gastrointestinal tract (Fig. 1B). A CT scan of the colon confirmed the existence of a pancreatic-colonic fistula (Fig. 2A). Conservative treatment was commenced with nil by mouth and levofloxacin-metronidazole. The fistula persisted despite clinical and analytical improvement. Leukocytosis and acute phase reactants reappeared when antibiotic therapy was discontinued after 2 weeks. Given the low rate of spontaneous resolution of this type of fistula, we performed

La imagen del mesNeumomediastino y enfisema cervical como comienzo de dehiscencia de anastomosis colorrectalPneumomediastinum and cervical emphysema as a debut of colorectal anastomotic leakage

The patient is an 83-year-old woman with Alzheimer’s who had been discharged 4 days earlier after a sigmoidectomy performed 11 days before due to sigmoid adenocarcinoma (pT3N0). She came to the hospital because of general malaise, cough and dyspnoea. Physical examination detected bilateral laterocervical subcutaneous emphysema. Work-up showed lactic acid 2.5 mmoL/L, neutrophils 12,860/mL and C-reactive protein 466.5 mg/L. A chest radiograph (Fig. 1) showed (from top to bottom) subcutaneous emphysema in the cervical region, pneumomediastinum and retropneumoperitoneum. Thoracoabdominal computed tomography (CT) with intravenous and endorectal contrast revealed, on the axial view (Fig. 2): retroperitoneal contrast (arrow), anastomotic dehiscence and adjacent extravasation of contrast (circle). The coronal slice demonstrated (Fig. 3): retropneumoperitoneum and extravasation of retroperitoneal contrast. The patient was treated surgically, at which time we found dehiscence of the colorectal anastomosis. Cultures were positive for Enterococcus, Bacteroides, Clostridium and Morganella morganii. Hartmann’s procedure was performed and a drain inserted. The patient was discharged 60 days later. c i r e s p . 2 0 1 5 ; 9 3 ( 8 ) : e 8 1