Escala predictiva de dehiscencia de la línea de sutura intestinal / A Predictive Scale for Dehiscence of the Intestinal Suture Line

Introducción: La dehiscencia de la línea de sutura es una de las complicaciones más frecuentes en la cirugía intestinal. Objetivo: Diseñar una escala predictiva para estimar de forma individual la probabilidad de dehiscencia de la línea de sutura intestinal. Métodos: Se realizó un estudio, analítico, de cohorte con recogida retrospectiva de datos en el sexenio 2014-2019 en el hospital "Celia Sánchez Manduley". La muestra fue de 437 pacientes y se usó la variable dependiente: dehiscencia de la línea de sutura intestinal y variables independientes: edad, sexo, comorbilidad, hemoglobina, hipoalbuminemia, neoplasia de colon, riesgo anestésico, entre otras. Resultados: En el análisis multivariado se obtuvo un modelo ajustado con las variables: edad mayor de 70 años (p = 0,002), hipoalbuminemia (p = 0,014), anastomosis enterocólica (p = 0,018), cirugía urgente (p = 0,001) e íleo paralítico prolongado (p < 0,001). La escala predictiva fue derivada del modelo estadístico ajustado y clasificado en 3 grupos de riesgo la probabilidad de dehiscencia de la línea de sutura intestinal: bajo (menor de 2 puntos), moderado (entre 3 y 5 puntos) y elevado (mayor de 6 puntos). Presentó una sensibilidad de 89,6 por ciento, especificidad de 89,1 por ciento, porciento predictivo global de 89,2 por ciento, valor predictivo positivo de 66,1 por ciento y valor predictivo negativo de 97,2 por ciento. Tuvo una excelente calibración y un elevado poder discriminativo. Conclusión: Se obtuvo una escala predictiva para estimar de forma individual la probabilidad de dehiscencia de la línea de sutura intestinal(AU)

ABSTRACT Introduction: The suture line dehiscence is one of the most frequent complications in intestinal surgery. Objective: To design a predictive scale for estimating individual probability of suture line dehiscence. Methods: An analytical cohort study, which involved retrospective data collection, was carried out, in the six-year period of 2014-2019, at Celia Sánchez Manduley Hospital. The sample consisted of 437 patients. Dehiscence of the intestinal suture line was used as a dependent variable, while age, sex, comorbidity, hemoglobin, hypoalbuminemia, colon neoplasia, anesthetic risk, among others, were used as independent variables. Results: Through multivariate analysis, an adjusted model was obtained, with the following results for the variables: age over 70 years (P=0.002), hypoalbuminemia (P=0.014), enterocolic anastomosis (P=0.018), urgent surgery (P=0.001), and ileus prolonged paralytic (P < 0.001). The predictive scale was derived from the adjusted statistical model and, based on the probability of dehiscence of the intestinal suture line, classified into three risk groups: low (less than two points), moderate (between 3-5 points) and high (more than six points). It presented a sensitivity of 89.6 percent, a specificity of 89.1 percent, a global predictive percentage of 89.2 percent, a positive predictive value of 66.1 percent, and a negative predictive value of 97.2 percent. It had an excellent calibration and a high discriminative power. Conclusion: A predictive scale was obtained for estimating the individual probability of dehiscence of the intestinal suture line(AU)

Ascariasis hepatobiliar en una lactante con desnutrición severa: reporte de caso / Hepatobiliary ascariasis in severely malnourished infant: case report

Resumen La Ascariasis es la geohelminitiasis más común del mundo, catalogándose como una enfermedad tropical desatendida, que puede causar compromiso pulmonar, gastrointestinal, hepatobiliar y nutricional. Se presenta el caso inusual de una lactante procedente de una zona de extrema pobreza quien consultó por fiebre, vómito, ausencia de deposiciones, distensión y dolor abdominal. Fue diagnosticada con pseudoobstrucción intestinal, desnutrición severa, choque séptico de origen intraabdominal, retraso del neurodesarrollo y deprivación psicoafectiva, cuyas imágenes reportaron ascariasis hepatobiliar y granulomas hepáticos calcificados y abscedados, con infestación severa por Ascaris lumbricoides. Recibió manejo antibiótico y antiparasitario con recuperación exitosa. En nuestro medio, las infecciones por helmintos son causa frecuente de anemia, retraso cognitivo y del crecimiento en niños en edad escolar. Sin embargo, la infestación y complicaciones hepatobiliares como colangitis, colecistitis, pancreatitis, litiasis biliar y hepatitis abscedada son inusuales en menores de dos años. A través de este caso se pretende resaltar la presentación atípica de la enfermedad en lactantes e incitar al fortalecimiento de las intervenciones en salud pública. MÉD.UIS.2020;33(1):67-72.

Abstract Ascariasis is the most common geohelminitiasis in the world. It is categorized as an unattended tropical disease, which can cause pulmonary, gastrointestinal, hepatobiliary and nutritional compromise. We present the unusual case of an infant from an extreme poverty area presenting fever, vomiting, absence of bowel movements, bloating and abdominal pain. She was diagnosed with intestinal pseudoobstruction, severe malnutrition, abdominal septic shock, neurodevelopmental delay and emotional deprivation. The images reported hepatobiliary ascariasis and calcified and abscessed hepatic granulomas, with severe infestation by Ascaris lumbricoides and Trichuris trichiura. She was treated with antibiotics and antiparasitic agents with successful recovery. In our environment, helminth infections are a frequent cause of anemia, stunting and neurodevelopmental delay in school-age children. However, infestation and hepatobiliary complications such as cholangitis, cholecystitis, pancreatitis, biliary lithiasis and hepatic abscess are unusual in children under two years old. Through this case, it is intended to highlight the atypical presentation of this disease at the age of this patient and encourage the strengthening of public health interventions. MÉD.UIS.2020;33(1):67-72.

Íleo paralítico em três bovinos: relato de caso / Paralytic ileus in three cattle: case report

O íleo paralítico é uma obstrução do tipo funcional, na qual o lúmen intestinal está patente, comprometendo a passagem da ingesta no intestino. Este relato objetiva descrever três casos em vacas com aptidão leiteira, atendidos na rotina hospitalar e diagnosticados com íleo paralítico. Em seus históricos, os proprietários queixavam-se que os animais apresentavam redução do apetite, timpania ruminal, diminuição da produção de leite e eliminação das fezes. Ao exame físico, alguns sinais clínicos apresentaram destaque, como apatia, desidratação, redução da motilidade ruminal e intestinal, fezes em pequena quantidade e com muco, distensão do abdômen e ao balotamento constatou-se a presença de líquido. Na análise do fluido ruminal todos os animais apresentaram o teor de cloreto elevado (>30 mEq/L), caracterizando, dessa forma, um processo obstrutivo. Diante dos achados, suspeitou-se inicialmente de um quadro de obstrução intestinal. Nos casos, a conduta adotada foi realizar uma laparotomia exploratória através do flanco direito, porém constatou-se, que não existia qualquer segmento com obstrução de natureza mecânica, que justificasse as alterações físicas e laboratoriais encontradas. Diante destes resultados, configurou-se um quadro clínico indicativo de íleo paralítico. As vacasforam submetidas a um protocolo terapêutico pós-cirúrgico composto por antibioticoterapia, anti-inflamatório, cálcio, procinético e tratamento de suporte. Os animais manifestaram uma resposta favorável a conduta terapêutica, com restabelecimento da função gastrointestinal e dos demais parâmetros fisiológicos, recebendo alta após uma evolução clínica variando entre dez a doze dias.

Paralytic ileus is an obstruction of the functional type, in which the intestinal lumen is patent, compromising the passage of the intake in the intestine. The objective of this study was to describe three cases in dairy cows treated in the hospital routine diagnosed with paralytic ileus. In their histories, the owners complained that the animals presented reduced appetite, ruminal tympany, decreased milk yield and elimination of faeces. At the physical examination, some clinical signs were prominent in both, such as apathy, dehydration, reduction of ruminal and intestinal motility, faeces were present in small quantity and with mucus present, abdominal enlargement and the succession produced sloshing sounds. In the analysis of the ruminal fluid, the chloride content in both was high (>30 mEq/L), characterizing an obstructive process. In the face of the findings, a diagnosis of intestinal obstruction was initially suspected. In animals, the adopted approach was to perform an exploratory laparotomy through the right flank, but it was verified that there was no segment with mechanical obstruction that justified the physical and laboratorial alterations found. In view of these results, a clinical diagnosis indicative of paralytic ileus was established. The three animals were submitted to a post-surgical therapeutic protocol consisting of antibiotic therapy, anti-inflammatory, calcium, pro-kinetic and supportive treatment. The animals showed a favourable response to therapeutic treatment, with restoration of gastrointestinal function and other physiological parameters, and was discharged after a clinical evolution ranging from ten to twelve days.

Íleo paralítico em três bovinos: Relato de caso / Paralytic ileus in three cattle: case report

O íleo paralítico é uma obstrução do tipo funcional, na qual o lúmen intestinal está patente, comprometendo a passagem da ingesta no intestino. Este relato objetiva descrever três casos em vacas com aptidão leiteira, atendidos na rotina hospitalar e diagnosticados com íleo paralítico. Em seus históricos, os proprietários queixavam-se que os animais apresentavam redução do apetite, timpania ruminal, diminuição da produção de leite e eliminação das fezes. Ao exame físico, alguns sinais clínicos apresentaram destaque, como apatia, desidratação, redução da motilidade ruminal e intestinal, fezes em pequena quantidade e com muco, distensão do abdômen e ao balotamento constatou-se a presença de líquido. Na análise do fluido ruminal todos os animais apresentaram o teor de cloreto elevado (>30 mEq/L), caracterizando, dessa forma, um processo obstrutivo. Diante dos achados, suspeitou-se inicialmente de um quadro de obstrução intestinal. Nos casos, a conduta adotada foi realizar uma laparotomia exploratória através do flanco direito, porém constatou-se, que não existia qualquer segmento com obstrução de natureza mecânica, que justificasse as alterações físicas e laboratoriais encontradas. Diante destes resultados, configurou-se um quadro clínico indicativo de íleo paralítico. As vacas foram submetidas a um protocolo terapêutico pós-cirúrgico composto por antibioticoterapia, anti-inflam

Paralytic ileus is an obstruction of the functional type, in which the intestinal lumen is patent, compromising the passage of the intake in the intestine. The objective of this study was to describe three cases in dairy cows treated in the hospital routine diagnosed with paralytic ileus. In their histories, the owners complained that the animals presented reduced appetite, ruminal tympany, decreased milk yield and elimination of faeces. At the physical examination, some clinical signs were prominent in both, such as apathy, dehydration, reduction of ruminal and intestinal motility, faeces were present in small quantity and with mucus present, abdominal enlargement and the succession produced sloshing sounds. In the analysis of the ruminal fluid, the chloride content in both was high (>30 mEq/L), characterizing an obstructive process. In the face of the findings, a diagnosis of intestinal obstruction was initially suspected. In animals, the adopted approach was to perform an exploratory laparotomy through the right flank, but it was verified that there was no segment with mechanical obstruction that justified the physical and laboratorial alterations found. In view of these results, a clinical diagnosis indicative of paralytic ileus was established. The three animals were submitted to a post-surgical therapeutic protocol consisting of antibiotic therapy, anti-inflammatory, calcium, pro-kinetic and supportive treatment. The animals showed a favourable response to therapeutic treatment, with restoration of gastrointestinal function and other physiological parameters, and was discharged after a clinical evolution ranging from ten to twelve days.

Enteroscopia asistida por balón simple en el manejo de la patología del intestino delgado: Experiencia de la Unidad de Intestino Delgado de la Clínica Anglo Americana durante el periodo de diciembre del 2012 a diciembre del 2018 / Single balloon enteroscopy in the management of small bowel pathology: Experience of the Small Bowel Unit - British American Hospital from December 2012 to December 2018

Objetivo: Describir la experiencia en el uso de la enteroscopia asistida por balón simple para el diagnóstico y manejo de la patología del intestino delgado en pacientes con anatomía normal y alterada por cirugía en la Clínica Anglo Americana. Material y método: El presente es un estudio descriptivo - retrospectivo que incluye a todos los pacientes que acudieron a la Unidad de Intestino Delgado de la Clínica Anglo Americana, para realizarse una enteroscopia asistida por balón durante el periodo comprendido entre diciembre del 2012 a diciembre del 2018. Resultados: Se realizaron 80 procedimientos de enteroscopia asistida por balón simple, 49 fueron realizados por via anterógrada y 31 por vía retrógrada. La edad promedio fue 60,78 años (20 a 88 años). 48 pacientes (60%) eran varones. El tiempo de inserción media fue 80 minutos para la vía anterógrada (55 - 141 minutos) y 110 minutos para la vía retrógrada (55 -180 minutos). La principal indicación para realizar la enteroscopia por balón simple fue hemorragia digestiva oscura, 45 casos (56,25%). Se realizaron 6 estudios de enteroscopias asistida por balón en pacientes con anatomía alterada (7,5%). Setenta de los ochenta procedimientos (87,5%) fueron realizados con sedación administrada por enfermería supervisada por gastroenterólogo en base a midazolam, petidina y propofol, no se presentó ninguna complicación respiratoria o hemodinámica. Los diagnósticos obtenidos más frecuentes por enteroscopia fueron: angiodisplasias de intestino delgado (20%), úlceras yeyuno ileales (17,5%) y neoplasias a nivel del intestino delgado (7,5%). La complicación que se presentó con más frecuencia posterior a la enteroscopia fue el íleo paralítico, 2 casos, y se asoció a no utilizar insuflación con dióxido de carbono durante el procedimiento. Conclusiones: La hemorragia digestiva oscura fue la principal indicación para realizar una enteroscopia asistida por balón simple. Los diagnósticos más frecuentes fueron angiodisplasias, úlceras yeyuno ileales y neoplasias a nivel del intestino delgado. La complicación más frecuente fue el íleo paralítico y se asoció a no utilizar insuflación con dióxido de carbono durante el procedimiento.

Objetive: To describe our experience with single balloon enteroscopy in the management of small bowel disease in British American Hospital, Lima - Perú. Material and methods: Descriptive and prospective study. We include all patients that come to perform a single balloon enteroscopy in small bowel unit of British American Hospital within December 2012 to December 2018. Results: We performed 80 procedures of single balloon enteroscopy, 49 were done by oral approach, 31 by rectal approach. Mean age were 60.78 years-old (20 - 88 years). 48 patients (60%) were male. The mean insertion time for oral approach was 80 minutes (55-141 minutes), and for rectal approach was 110 minutes (55-180 minutes). The main indication for single balloon enteroscopy was obscure gastrointestinal bleeding. 6 enteroscopies were performed in patients with altered surgical anatomy (7.5%). 70 of 80 procedures (87.5%) were performed with gastroenterology-administered sedation, using midazolam, pethidine and propofol, without any respiratory or hemodinamic complication. Diagnostics achieved by single balloon enteroscopy were small bowel angiodysplasias (20%), yeyuno ileal ulcers (17.5%) and small bowel neoplasia (7.5%). Paralytic ileus was the most common complication of single balloon enteroscopy, 2 cases, and both cases were associated after no using carbon dioxide insufflation during procedure. Conclusion: Obscure gastrointestinal bleeding was the main indication for single balloon enteroscopy. Diagnostics achieved by single balloon enteroscopy were small bowel angiodysplasias (20%), yeyuno ileal ulcers (17.5%) and small bowel neoplasia (7.5%). Paralytic ileus was the most common complication of single balloon enteroscopy, 2 cases, and both cases were associated after no using carbon dioxide insufflation during procedure

Seudoobstrucción colónica aguda o síndrome de Ogilvie en una anciana / Acute colonic pseudo-obstruction or Ogilvie syndrome in an old woman

La seudoobstrucción colónica aguda o síndrome de Ogilvie es una afección en la cual hay apariencia clínica e imagenológica de obstrucción intestinal sin bloqueo mecánico. Se describe el caso clínico de una anciana de 65 años de edad, quien sufría esta condición clínica, por lo cual fue atendida en el Servicio de Cirugía del Hospital N´Gola Kimbanda, provincia Namibe en Angola e intervenida quirúrgicamente. La paciente evolucionó favorablemente y egresó sin dificultad

The acute colonic pseudo-obstruction or Ogilvie syndrome is a disorder in which there is a clinical and imagenologic appearance of intestinal obstruction without mechanic blockade. The case report of a 65 years old woman who suffered from this clinical condition is described, reason why she was assisted and surgically intervened in the Surgery Service of N´Gola Kimbanda Hospital, Namibe province in Angola. The patient had a favorable clinical course and she was discharged without difficulty

Tratamiento exitoso con inmunoglobulinas intravenosas en un paciente con pseudoobstrucción intestinal asociada a lupus eritematoso sistémico / Successful treatment with intravenous immunoglobulins in a patient with intestinal pseudo-obstruction associated with systemic lupus erythematosus

Resumen El compromiso gastrointestinal en pacientes con lupus eritematoso sistémico (LES) es muy diverso. Su frecuencia y ubicación a lo largo del tracto digestivo varían ampliamente. Los procesos inflamatorios secundarios a los depósitos de complejos inmunes o eventos vasculares pueden ser los causantes de este compromiso. Una de las manifestaciones gastrointestinales características en los pacientes con LES es la pseudoobstrucción intestinal, que se define como la propulsión intestinal ineficaz que se produce en ausencia de factores mecánicos u obstructivos. Esta es, sin embargo, una complicación rara y poco entendida del LES. En este artículo, reportamos el caso de un paciente masculino con diagnóstico de LES y pseudoobstrucción intestinal, que fue tratado exitosamente con esteroides e inmunoglobulinas intravenosas. Se presenta una revisión completa de la literatura y una propuesta de la fisiopatología de la manifestación.

Abstract Gastrointestinal involvement in patients with systemic lupus erythematosus (SLE) is very diverse, and the frequency of occurrence and location along the digestive tract varies widely. Inflammatory processes secondary to immune complex deposits or vascular events may cause this involvement. One of the most characteristic gastrointestinal manifestations in these patients is the intestinal pseudo-obstruction, which is defined as the ineffective intestinal propulsion that occurs in the absence of mechanical or obstructive factors. This is, however, a rare and poorly understood complication of SLE. The case is presented of a male SLE patient presenting with intestinal pseudo-obstruction, and was successfully treated with steroids and intravenous immunoglobulin. A complete review of the literature and a proposal for the pathophysiology of intestinal pseudo-obstruction are presented.

Tres casos de síndrome de ogilvie en manejo crónico con clozapina. Clínica San Juan de Dios, Chía, Colombia / Three cases of ogilvie´s syndrome in patients with chronic medication with clozapine - Clínica San Juan de Dios, Chía, Colombia

El síndrome de Ogilvie es una condición clínica con signos, síntomas y hallazgos radiográficos de obstrucción intestinal sin una causa mecánica. La fisiopatología es aún desconocida, se sugiere un disbalance entre la inervación simpática y parasimpática del colon. Se asocia con una extensa gama de comorbilidades incluyendo trauma, cirugía pélvica (ortopédica, ginecológica, urológica), alteraciones metabólicas o del sistema nervioso central, así como medicamentos en especial antipsicóticos atípicos como clozapina. Sin el diagnóstico y tratamiento oportunos puede progresar a perforación intestinal, peritonitis e incluso la muerte. Se analizan las historias clínicas de tres pacientes tratados por pseudoobstrucción intestinal (síndrome de Ogilvie) en la Clínica San Juan de Dios de Chía, Colombia, en 2011, que requirieron remisión para manejo médico o quirúrgico. Se consideró como causa desencadenante el uso crónico del antipsicótico clozapina...

Ogilvie´s syndrome is a clinical condition with signs, symptoms and radiographic appearance of intestinal obstruction without a mechanical cause. Pathophysiology is still unknown. An imbalance between sympathetic and parasympathetic colonic innervation is suggested. It is associated with an extent range of comorbidities including trauma, pelvic surgery (orthopedic, gynecologic, urologic), metabolic alterations or central nervous system alterations, as well as in patients receiving medication especially atypical anti-psychotic agents such as clozapine. Prompt diagnosis and treatment are critical to avoid progression to bowel perforation, peritonitis and even death. Clinical records of 3 patients treated for bowel pseudo-obstruction (Ogilvie´s Syndrome) at San Juan de Dios Clinic in Chía, Colombia, in 2011, who needed referral for medical or surgical treatment, were analyzed. Chronic use of clozapine, an antipsychotic agent, was considered the triggering cause. Peritonitis and bowel perforation was the most serious complication. There was no mortality attributable to this syndrome or its management...

Sobrecrecimiento bacteriano intestinal y pseudoobstrucción intestinal crónica: una relación poco conocida / Small intestinal bacterial overgrowth and chronic intestinal pseudo-obstruction

Chronic intestinal pseudo-obstruction (CIP) is the most severe intestinal motility disorder. Small intestinal bacterial overgrowth (SIBO) is frequently associated to dysmotility. In spite of this association, there is scare data on the relation between CIP and SIBO. To establish occurrence of CIP in SIBO patients in inter-crisis periods. To compare clinical and manometric characteristics of SIBO and non-SIBO patients. Retrospective analysis of 40 CIP patients (average age: 41 years; range: 18-76 years; 75 percent women). The following elements were registered: symptoms (such as pain, distention, vomit, constipation, diarrhea and weight loss); findings of the intestinal manometry (neuropathic, miopatic and mix pattern; intestinal motility index); and SIBO using lactulose H2 breath test, defined as an increase > 20 ppm in 2 or more figures in the first 60 minutes. Statistical analysis: t-test y and comparison of two ratios. SIBO was observed in 60 percent of the patients with CIP. Three or more symptoms were observed in 70.8 percent of the patients with SIBO 50 percentwithout SIBO (p = NS). In patients with SIBO, the most frequent symptom was abdominal pain (70.8 percent p= 0.032). There were no differences between SIBO patients and the different motility patterns, however, the intestinal motility index was lower for the SIBO group (9.7 +/- 44 12.3 +/-7; p < 0.001). : There is a high prevalence of SIBO in CIP patients. This is associated to a major compromise of intestinal motility assessed by the intestinal motility index...

Introducción: La pseudoobstrucción intestinal crónica (POIC) es el trastorno más grave de la motilidad intestinal. El sobrecrecimiento bacteriano intestinal (SBI) se asocia frecuentemente a estados de dismotilidad. A pesar de esta asociación existen escasos datos sobre la relación entre POIC y SBI. Objetivo: Determinar SBI en pacientes con POIC en período inter-crisis. Comparar características clínicas y manométricas de pacientes con y sin SBI. Material y Método: Análisis retrospectivo de 40 pacientes con POIC (edad promedio: 41 años, rango: 18-76 años; 75 por ciento mujeres). Se registraron síntomas (dolor, distensión, vómitos, constipación, diarrea, baja de peso), hallazgos en manometría intestinal (patrón neuropático, miopático o mixto, índice de motilidad intestinal (IMI)) y SBI con test de H2 con lactulosa, definido como la elevación > 20 ppm en 2 o más cifras en los primeros 60 min. Análisis estadístico: t-test y comparación de 2 proporciones. Resultados: Se observó SBI en 60 por ciento de los pacientes con POIC. Tres o más síntomas se presentaron en 70,8 por ciento de los pacientes con SBI vs 50 por ciento en POIC sin SBI (p = NS). El síntoma dolor abdominal fue más frecuente en pacientes con SBI (70,8 por ciento vs 31,2 por ciento, p = 0,032). No hubo diferencias entre pacientes con SBI y los distintos patrones de motilidad, sin embargo, el IMI fue menor para el grupo con SBI (9,7 +/- 1,44 vs 12,3 +/- 1,7, p < 0,001). Conclusiones: Existe una alta prevalencia de SBI en pacientes con POIC. Esto se relaciona con mayor compromiso de la motilidad intestinal evaluado por el IMI.

Trasplante multivisceral modificado con preservación de bazo, duodeno y páncreas del receptor: técnica quirúrgica y primera experiencia latinoamericana / Modified multivisceral transplant with preservation of native spleen, duodenum and pancreas: surgical technique and Latin American experience

La cirugía de trasplantes se desarrolla cada día más en Colombia y en el mundo; este artículo presenta la experiencia mundial y la primera en Latinoamérica del trasplante multivisceral modificado con preservación del bazo, el duodeno y el páncreas del receptor. Las indicaciones para este trasplante son la insuficiencia gastrointestinal irreversible sin insuficiencia hepática (con dependencia completa de nutrición parenteral total para vivir) secundaria a neuropatías o miopatías generalizadas del tubo digestivo (pseudoobstrucción intestinal crónica), y la enfermedad de Crohn con compromiso extenso del estómago, el duodeno y el intestino delgado. La técnica quirúrgica para este tipo de trasplante fue desarrollada por Kareem Abu-Elmagd en la Universidad de Pittsburgh (Pensilvania, Estados Unidos), quien ha reportado ya 24 pacientes, con una supervivencia del injerto del 96 % a un año, 85 % a dos años, 70 % a tres años y 63 % a cuatro años, con una completa autonomía nutricional en más del 90 % de los casos. En Latinoamérica, solamente se han realizado dos trasplantes de este tipo en el Hospital Pablo Tobón Uribe (Medellín, Colombia), de los cuales, uno ya cumplió tres años con total autonomía nutricional y retorno completo a sus actividades sociales y laborales. Con esta revisión se desea mostrar que el trasplante multivisceral modificado con preservación del bazo, el duodeno y el páncreas del receptor, ya es una realidad en el mundo y en nuestro país, con resultados cada vez más cercanos a los obtenidos con los órganos sólidos intraabdominales (hígado y riñón).

Transplant surgery takes place every day in Colombia and in the world; this paper shows the global and the first Latin American experience of modified multivisceral transplant with preserved native spleen, duodenum and pancreas. The indications for this transplant are the irreversible gastrointestinal failure without hepatic insufficiency (with complete reliance of total parenteral nutrition to live) secondary to generalized gastrointestinal tract neuropathies or myopathies (chronic intestinal pseudo-obstruction), and Crohn's disease with extensive stomach, duodenum and small intestine involvement. The surgical technique for this type of transplant was developed by Dr. Kareem Abu-Elmagd, at the University of Pittsburgh (Pennsylvania - United States), who has already reported 24 patients, with a 96% 1 year graft survival, 85% at 2 years, 70% at 3 years and 63% at 4 years, with complete nutritional autonomy in more than 90% of patients. In Latin America only 2 transplants of this type have been done, both at the Pablo Tobón Uribe Hospital (Medellin - Colombia), of which one already completed 3 years with a complete nutritional autonomy and full return to their occupational and social activities. With this paper we want to show that the modified multivisceral transplant with preservation of native spleen, duodenum and pancreas is already a reality in the world and in our country, with results increasingly closer to those obtained with the solid intra-abdominal organ (liver and kidney).

Intestinal obstruction and pseudo-obstruction in patients with systemic sclerosis / Intestinal obstruction and pseudo-obstruction in patients with systemic sclerosis.

Chronic intestinal pseudo-obstruction is a known complication of patients with systemic sclerosis, manifested as nausea, vomiting, constipation, abdominal distension and pain. We report a series of cases with systemic sclerosis that presented with signs of intestinal obstruction. In all cases, the differentiation between a pseudo-obstruction and true mechanical obstruction remained a formidable challenge. Our goal was to present different scenarios of patients with systemic sclerosis and features of intestinal obstruction, with a review on its clinical approach.

Beneficio de la goma de mascar vs metoclopramida en la prevención del íleo postoperatorio de laparotomía / Benefit of chewing gum vs metoclopramide in the prevention of postoperative ileus ofter laparotomy

Analizar el beneficio de la goma de mascar y la metoclopramida en la prevención del íleo postoperatorio de laparotomía, Hospital Victorino Santaella Ruíz, octubre-noviembre 2009. Estudio prospectivo, cuasiexpemental. Un total de 60 pacientes post-operados de laparotomía fueron seleccionados y distribuidos equitativamente en 3 grupos: metoclopramida, goma de mascar y grupo control. Se registro el inicio de ruidos hidroaéreos, expulsión de flatos, evacuaciones y tolerancia completa a la vía oral en cada grupo. Los resultados fueron semetidos a un análisis de varianza de una sola vía y test de comparaciones múltiples. Con respecto al grupo control el grupo goma de mascar demostró ventaja al evaluar los factores ruidos hidroaéreos (p<0,05) y tolerancia completa a la vía oral (p<0.02). De la misma manera lo demostró el grupo metoclopramida (p<0,05) sobre el grupo control cuando se evaluó el factor flatos. Y en relación al factor evacuaciones ambos grupos terapéuticos demostraron igual superioridad sobre el grupo control (p<0.02). No se observaron diferencias significativas entre los grupos goma de mascar y metoclopramida. No se observaron diferencias significativas entre la administración de goma de mascar y metoclopramida, sin embargo al compararlos individualmente con el grupo control ambos mostraron beneficios estadísticamente significativos, que fueron mayores cuantitativamente en el grupo goma de mascar. En base a lo anterior y a otras ventajas como; la virtual ausencia de efectos secundarios, su bajo costo, su fácil y amplia disponibilidad, podemos recomendar el uso de goma de mascar para la prevención del íleo postoperatorio.

Analyze the benefit of chewing gum and metoclopramide in the prevention of postoperative ileus after laparotomy, Hospital Victorino Santaella Ruíz, octubre-november 2009. A prospective clinical trial carried out on 60 post-operatives of laparotomy patients. They were randomly assigned into three groups: metoclopramide, chewing gum and control group. The beginning of bowel sounds, flatus, bowel movements and complete food tolerance were recorded in each group. The data were analysed using the one-way variance method and the multiple comparison test. With respect to control group, the chewing gum group showed some statistical advantage when the factor, bowel sounds and complete food tolerance were compared (p<0,05) and (p<0.02) respectively. Metoclopramide showed advantage over the control group in regard to flatus factor (p<0,05). For the bowel movement factor, both therapeutic groups showed identical superiority compared to control group (p<0.02). There was no statistical diference between metoclopramide and chewing gum groups. There were not statistical difference between both therapeutic groups; nevertheless, when both of them were compared individually with the control group, the chewing gum group showed cuantitatively more advantages than metoclopramide group in the prevention of postoperative ileus. Based on the previously describe and other advantages as absence of side effects low cost and easy accessibility we can recommend the use of chewing gum in the prevention of postoperative ileus.

Síndrome de Ogilvie (pseudo-obstrução intestinal aguda) - Relato de caso / Ogilvie's Syndrome (Acute pseudo-intestinal obstruction) - A case report

RACIONAL: A síndrome de Ogilvie é condição clínica com sinais, sintomas e aparência radiológica de dilatação acentuada do cólon sem causa mecânica e pode complicar com rompimento da parede do cólon e sepse abdominal. O tratamento na maioria das vezes é cirúrgico. RELATO DO CASO: Paciente feminina, 49 anos, internada com queixa de dor abdominal e diarréia e apresentando-se confusa, desidratada, taquicárdica, dispnéica, temperatura de 38ºC, abdômen distendido, ausência de ruídos hidro-aéreos e toque retal com fezes pastosas. Estudo radiográfico mostrou padrão de pseudo-obstrução intestinal. A paciente evoluiu com parada de eliminação de gases e fezes e sinais de abdômen agudo infeccioso. Foi submetida à laparotomia com achado de ceco e transverso bastante dilatados e sem sinal de obstrução mecânica. Realizada colectomia subtotal com fechamento do coto distal e ileostomia terminal. CONCLUSÃO: Pensar nessa possibilidade diagnóstica e agir mais rapidamente é a única possibilidade de diminuir a morbimortalidade desses pacientes.

BACKGROUND: The Ogilvie's Syndrome is a clinical condition with signals, symptoms and radiological appearance of large bowel swell without mechanical cause. This obstruction can complicate with disruption of the bowel and consequent evolution of abdominal sepse. The treatment is typically surgical. AIM: The aim of this work is report a case of Ogilvie's Syndrome. CASE REPORT: Feminine patient, 49 years-old, interned with a history of abdominal pain and diarrhea and presenting dehydratation, tachycardia , dyspnea, mental confusion, 38ºC of temperature, distended abdomen, absence of hydro-aerial noises and rectal touch with pasty excrements. The x-ray showed a standard of pseudo-intestinal obstruction. The patient evolved with stop of elimination of farts and excrements and signals of infectious acute abdomen. The laparotomy showed cecum and transverse very swelled without signal of mechanical obstruction. The treatment was a subtotal colectomy with closing of the rectal stump and terminal ileostomy. CONCLUSION: This is rare syndrome and cases like this must be described for a faster diagnostic and adequate treatment, reducing the morbimortality of these patients.

Unusual occurrence of intestinal pseudo obstruction in a patient with maternally inherited diabetes and deafness (MIDD) and favorable outcome with coenzyme Q10 / Pseudo-obstrução intestinal em paciente com diabetes mitocondrial que apresentou boa resposta ao tratamento adjunto com coenzima Q10

Maternally inherited diabetes and deafness (MIDD) has been related to an A to G transition in the mitochondrial tRNA Leu (UUR) gene at the base pair 3243. This subtype of diabetes is characterized by maternal transmission, young age at onset and bilateral hearing impairment. Besides diabetes and deafness, the main diagnostic features, a wide range of multisystemic symptoms may be associated with the A3243G mutation. Organs that are most metabolically active, such as muscles, myocardium, retina, cochlea, kidney and brain are frequently affected. Gastrointestinal tract symptoms are also common in patients with mitochondrial disease and constipation and diarrhea are the most frequent manifestations. However, there are few prior reports of intestinal pseudo obstruction in MIDD patients. Here we report the case of a patient with MIDD associated with the mtDNA A3243G mutation who developed chronic intestinal pseudo obstruction, and the introduction of Coenzyme Q10 as adjunctive therapy led to a solution of the pseudo obstruction.

Diabetes mitocondrial ou diabetes e surdez de herança maternal (MIDD, acrônimo de maternally inherited diabetes and deafness) é freqüentemente associado à mutação mitocondrial A3243G. Esse subtipo de diabetes é caracterizado por transmissão materna, disacusia neuro-sensorial bilateral e idade precoce de aparecimento. Além do diabetes e da surdez, principais características diagnósticas, outros sintomas em diferentes órgãos podem também associar-se à mutação A3243G. Os órgãos que são metabolicamente mais ativos, tais como músculos, miocárdio, retina, cóclea, rim e cérebro, são freqüentemente afetados. Sintomas do trato gastrintestinal também são comuns em pacientes com doença mitocondrial, sendo diarréia e obstipação as manifestações mais freqüentes. Entretanto, há poucos relatos de pseudo-obstrução intestinal em portadores de diabetes mitocondrial. Este relato descreve o caso de uma paciente com diabetes mitocondrial que apresentou pseudo-obstrução intestinal e que com a introdução de coenzima Q10, como terapia adjunta, teve resolução o quadro.

Colectomias no tratamento cirúrgico da constipação intestinal crônica - relato de quatro casos / Colectomy in the surgical treatment of chronic intestinal constipation

INTRODUÇÃO: A constipação intestinal é um distúrbio do trato digestório em que a atividade intestinal está reduzida, assim como a freqüência de evacuações; associada a fezes secas e endurecidas, acumuladas devido ao longo tempo de permanência no cólon. OBJETIVO: Avaliar quatro pacientes submetidos à colectomia total para o tratamento da constipação intestinal. MÉTODO: Estudo retrospectivo realizado por meio do levantamento de prontuários de pacientes submetidos à ressecção cirúrgica do cólon no tratamento da constipação intestinal crônica no período de 1998 a 2006. RESULTADOS: Em nossa casuística, que envolve o HUT e uma paciente operada no Hospital São Lucas de Taubaté, quatro pacientes foram submetidos à colectomia total para o tratamento da constipação intestinal crônica. Todos eram do sexo feminino, com mais de 30 anos de idade e apresentavam uma evolução do quadro há mais de 10 anos. Os resultados obtidos foram considerados satisfatórios por três pacientes, apesar de uma delas evacuar seis ou mais vezes ao dia. A quarta paciente referiu permanência do quadro, evacuando uma vez a cada sete dias, em média. CONCLUSÃO: O tratamento cirúrgico é uma alternativa nos casos crônicos incapacitantes, refratários a outras formas de tratamento. Os pacientes com indicação cirúrgica devem antes ser submetidos a uma evolução fisiológica e investigação clínica completa, para confirmação do quadro de inércia colônica.

INTRODUCTION: The intestinal constipation is a disturb of the alimentary tract in which its activity is reduced, as well as the frequency of evacuations; associated to dry and hardened excrements witch accumulate because of the long permanence in colon. OBJECTIVE: To evaluate four patients submitted to the total colectomy for the treatment of the intestinal constipation. METHOD: Retrospective study carried through by the analysis of handbooks of patients submitted to the surgical removal of colon in the treatment of the chronic intestinal constipation, in the period of 1998 the 2006. RESULTS: In our casuistry, that involves the HUT and a patient operated at Taubaté's São Lucas Hospital, four patients were submitted to total colectomy for treatment of chronic intestinal constipation. They were all of the feminine sex, with more than 30 years of age and presented more than 10 years of evolution. The results were considered satisfactory by three patients, although one of them evacuate six or more times in a day. The fourth patient related the permanence of the constipation, defecating a time to each seven days, on average. CONCLUSION: The surgical treatment is an alternative in the incapacities chronic cases refractory to other forms of treatment. The patients with surgical indication must be submitted to a physiological evolution and complete clinical inquiry, to confirm of the colonic inertia.

Chronic idiopathic intestinal pseudo-obstruction treated with jejunostomy: case report and literature review

CONTEXT: Chronic idiopathic intestinal pseudo-obstruction is a very rare condition. CASE REPORT: This study describes a male patient who had presented obstructive symptoms for 24 years. He had been treated clinically and had undergone two previous operations in different services, with no clinical improvement or correct diagnosis. He was diagnosed with intestinal obstruction without mechanical factors in our service and underwent jejunostomy, which had a significant decompressive effect. The patient was able to gain weight and presented improvements in laboratory tests. Jejunostomy is a relatively simple surgical procedure that is considered palliative but, in this case, it was resolutive.

CONTEXTO: A pseudo-obstrução intestinal crônica idiopática é uma causa rara de obstrução intestinal. RELATO DE CASO: O presente estudo relata o caso de um paciente com queixas obstrutivas há longa data (24 anos); sendo já submetido a tratamentos clínicos e a duas laparotomias em outro serviço, não houve melhora dos sintomas e nem elucidação do diagnóstico. Foi diagnosticada obstrução intestinal sem fator mecânico e o paciente foi submetido a jejunostomia em nosso serviço, tendo apresentado importante efeito descompressivo. Houve ganho de peso ponderal e melhora nos exames laboratoriais. A jejunostomia é um procedimento cirúrgico relativamente simples, considerada paliativa, mas nesse caso, teve caráter definitivo e resolutivo.

Semi-obstrução intestinal por esclerodermia: relato de caso / Intestinal semi-obstruction for scleroderma: case story

A esclerodermia ou esclerose sistêmica progressiva é uma doença auto-imune de causa desconhecida que se caracteriza por fibrose da pele, vasos sanguíneos e de alguns outros órgãos, como os pulmões, coração, rins e trato gastrointestinal. Sintomas atribuíveis ao comprometimento gastrointestinal podem estar presentes em até 50por cento dos pacientes, sendo os mais freqüentes, relacionados às manifestações esofagianas e anorretais. Anormalidades na motilidade intestinal com freqüência levam a desnutrição, supercrescimento bacteriano e quadro de pseudo-obstrução ou mesmo semi-obstrução intestinal. É apresentado um caso de paciente com esclerodermia há 43 anos, evoluindo com quadro de semi-obstrução, apresentando distensão abdominal, cólicas recorrentes e desnutrição grave. Sem resposta ao tratamento clínico foi submetida à cirurgia que evidenciou quadro obstrutivo por comprometimento ileal, o qual foi tratado por bypass íleo-cólico. Lesão intestinal por esclerodermia levando a quadro de obstrução é raramente descrita na literatura médica e, portanto, o tratamento de escolha ainda não foi definido.