Ruy Jorge Cruz Junior

Spontaneous cholecystocutaneous fistula: a rare complication of gallbladder disease

CONTEXT Spontaneous cholecystocutaneous abscess or fistula is an extremely uncommon complication secondary to cholecystitis. Over the past 50 years fewer than 20 cases of spontaneous cholecystocutaneous fistulas have been described in the medical literature. We here report a case of subcutaneous gallstone as a rare clinical presentation of the already uncommon cholecystocutaneous fistula. CASE REPORT An 81-year-old man presented with a large subcutaneous abscess in the right subcostal area with surrounding cellulitis and crepitus. An abdominal computed tomography scan showed two subcutaneous gallstones and communication between the abscess and the gallbladder. Cholecystectomy was performed and the abdominal wall abscess was drained externally. This case report demonstrates that maintaining a high degree of suspicion of this rare entity is helpful in achieving correct preoperative diagnosis, and that computed tomography scan should be performed in all cases of unexplained abdominal wall suppuration or cellulitis.

Intestinal obstruction induced by a giant incarcerated Spigelian hernia: case report and review of the literature

CONTEXT Spigelian hernia is an uncommon spontaneous lateral ventral hernia with an incarceration ratio of around 20%. However, complications such as intestinal obstruction are extremely rare. We report on a case of giant incarcerated Spigelian hernia with a clinical condition of complete intestinal obstruction that was treated using prosthetic polypropylene mesh. CASE REPORT A 72-year-old woman was admitted to the emergency department complaining of diffuse abdominal pain. Abdominal examination revealed a firm 10 x 10 cm tender mass in the lower left quadrant, without surrounding cellulite or tenderness. Plain abdominal radiographs displayed the formation of levels, thus indicating the existence of intestinal obstruction. An abdominal computed tomography scan clearly showed a fluid and air-filled mass in the soft tissue area of the lower left-side abdominal wall. Spigelian incarcerated hernia was diagnosed and the patient underwent emergency surgical repair by means of local incision. The large defect in the abdominal wall was closed up as successive anatomical layers, and a prosthetic polypropylene mesh was set into the lateral aspect of the rectus sheath. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day.

Efeitos iniciais da reposição volêmica com solução salina hipertônica a 7,5% na perfusão e oxigenação esplâncnica após choque hemorrágico

OBJETIVO: Avaliar os efeitos hemodinâmicos sistemicos e esplâncnico da expansao volemica inicial com SSH em modelo de choque hemorragico controlado. METODOS: Dez caes foram submetidos a sangramento controlado (20 ml/min) ate uma pressao arterial media de 40±5 mmHg (PAM). Apos 30 minutos de choque, receberam 4 ml/Kg de SSH em 5 minutos e posteriormente observados sem intervencoes adicionais durante 60 minutos. As variaveis hemodinâmicas sistemicas foram obtidas de um cateter arterial e de um cateter de Swan-Ganz, enquanto as regionais atraves da cateterizacao da veia porta, fluxometro ultrassonico na veia porta e um tonometro na cavidade. A oferta, taxa de extracao e consumo esplâncnico de oxigenio, pH intramucoso e os gradientes veno-arterial, porta-arterial e mucosa-arterial da pCO2 (Dap-apCO2, Dvp-apCO2 e Dt-apCO2, respectivamente), foram calculados. RESULTADOS: A hemorragia (29,8±2,4 ml/Kg) reduziu a pressao arterial media (125±6 para 42±1 mmHg), o DC (1,9±0,2 para 0,6±0,1 L/min) e o fluxo porta (504±73 para 126±12 ml/min), enquanto elevou o Dap-apCO2 (5,3±0,8 para 19,9±1,6 mmHg), Dvp-apCO2 (5,4±1,4 para 22,6±2,1 mmHg) e o Dt-apCO2 (6,1±1,1 para 43,8±7,5 mmHg). A infusao de SSH resultou em recuperacao parcial dos fluxos sistemico e porta. Atenuou os gradientes de CO2 com menor impacto sobre o Dt-apCO2. CONCLUSAO: A SSH promoveu beneficios parciais na perfusao sistemica e esplâncnica, os quais foram especialmente limitados na microcirculacao regional, como demonstrado pelo Dt-apCO2. Alem disso, as variaveis sistemicas e regionais dependentes de oxigenio, nao refletem a adequacao da perfusao da mucosa gastrica, enfatizando a importância da monitorizacao deste territorio - pela tonometria - durante os estados de choque.

Early restoration of cocaine-induced splanchnic hypoperfusion in anesthetized dogs.

Although cardiovascular effects of cocaine have been well studied, little is known about its effects on splanchnic perfusion. We studied systemic and regional hemodynamic effects of acute cocaine intoxication in dogs under volatile anesthesia. Mechanically ventilated beagle dogs, randomized at 1.5% halothane (n = 7) or 2.25% sevoflurane (n = 7) anesthesia, received an intravenous bolus of cocaine (12 mg/kg over 5 min) followed by 0.22 mg/kg/min infusion over 30 min. They were observed for 60 min thereafter. Cardiac index (CI), heart rate (HR), mean arterial pressure (MAP), portal blood flow (PBF), gastric PCO2 (gas tonometry), blood gases, and lactate and cocaine levels were assessed. Cocaine bolus promoted significant reductions in CI (∼ 50%), HR (∼ 20%), MAP (∼ 20%), and PBF (∼ 50%), accompanied by increase in systemic and splanchnic oxygen extractions and in gastric mucosal–arterial PCO2 gradient. Those changes were maintained during cocaine infusion and returned to baseline values parallel to plasmatic cocaine clearance. Unlike other shock states, regional parameters, including gastric mucosal–arterial PCO2 gradient, were restored before systemic variables. A possible local vasodilatory effect of volatile agents could play a role in this phenomenon. Cocaine infusion in anesthetized animals promoted marked systemic and regional hemodynamic derangement, which was rapidly reversible with decay of cocaine plasmatic concentration.