Estrangulated obturatory hernia. Case report of a challenging diagnosis of obstructive syndrome.

INTRODUCTION AND IMPORTANCE: Obturator hernia accounts for less than 1 % of all documented cases of pelvic hernias. It most commonly presents as an obstructive syndrome in elderly, multiparous, slim women, characterized by a wider pelvis that facilitates the passage of the hernia sac through the obturator foramen alongside the obturator nerve. In this case, adhering to the SCARE (Updating Consensus Surgical CAse REport) checklist criteria, we present a typical scenario involving an elderly woman who was initially misdiagnosed with a fecaloma, concealing an obturator hernia. CASE REPORT: An 85-year-old patient, displaying prodromal signs of senile disease, presented for medical attention with incapacitating abdominal pain in the right iliac fossa, accompanied by nausea and vomiting. Rectal examination revealed the presence of a fecaloma, and glycerin administration was performed rectally. The patient's condition worsened with the development of mental confusion and hyperactive delirium. Abdominal Computer tomography scan (CT scan) revealed right obturator hernia with enteral segment insinuation and dilation of the proximal bowel. An infraumbilical laparotomy was performed. The herniation of an ileal segment and the right ovary through the obturator foramen was identified. The content proved irreducible to manual maneuvers, leading to obturator muscle section following the dissection of the Retzius space. The right round ligament of the uterus was sectioned, and we manage to preserve the Obturatory branch of the lumbar plexus throughout dissection. A polypropylene mesh was positioned and secured with non-absorbable sutures on the Cooper's ligament, iliac crest, and obturator muscle and segmental enterectomy with primary anastomosis using a linear stapler was performed. CLINICAL DISCUSSION: This demanding case brings to the spotlight the importance of reevaluating even the usual cases. We provide our experience bringing together an unusual diagnosis after the conduction of a once diagnosed fecaloma that almost went down to a perforated acute abdomen. Hence the importance of suspect obturator hernia in unknown obstructive abdomen in elderly women. CONCLUSION: With this report we aim to raise awareness of careful propaedeutic inquiry of acute abdomen. We provide our experience bringing together the diagnosis that agrees with our literature review. Elderly patients commonly challenge the clinical evaluation, especially those with signs of senile disease. Thereby, inkling hidden diagnosis in typical scenarios can improve the patient's care in emergency settings.

Morphometric evaluation of the linea alba in fresh corpses.

Purpose: Diastasis recti abdominis is an increase in the distance between the medial borders of the two rectus muscles. It is most often triggered after intra-abdominal pressure increases, such as postpartum or in obesity. Most publications are based on radiological studies or are done in certain subgroups, without unanimous reference values of the distance between the rectus abdominis or standardization. Methods: Forty-one cadavers were studied. Exclusion criteria: signs of abdominal trauma, major burns, presence of scar from previous abdominal surgery, clinical signs of abdominal hernia, and identification of hernia during cadaver dissection. Linea alba (LA) length, width, and thickness were measured with a flexible tape measure and digital caliper. Anatomical landmarks were established, and subdivisions were described based on them to compare the cadavers. Results: Sex and age had little effect on LA width, thickness, or length. Obesity (compared to normal weight) was the only variable that promoted an increase in the LA width (p < 0.01). The supraumbilical length varied with the total height of the evaluated cadavers (p < 0.01), but the infraumbilical length did not (p = 0.11). Conclusion: The general statistical results of this study, regarding the evaluation of LA measurements in cadavers, showed that ethnicity, sex, and age have little effect on the width, thickness, or length of the LA. LA width differed significantly with abdominal circumference.

Bone anchor as fixation method for abdominal wall reconstruction. A case report about a ten times recurred inguinal hernia.

INTRODUCTION: While the use of bone anchor fixation for abdominal wall reconstruction for supra-pubic incisional hernia is well described (Yee et al., 2008 [1]), we show in this case report, written in line with the SCARE criteria (Agha et al., 2020 [2]), a novel use of this tool as an adjunct in the repair of a ten time recurrent inguinal hernia. CASE REPORT: A 65 years old multiparous, diabetic non-obese female, with previous abdominoplasty was submitted for left inguinal hernia for ten times, between multiples complications between infection, more than one mesh excision by anterior approach and laparoscopic approach. The wide range of procedures culminated in a destruction of the abdominal wall, making it impossible for a usual fixation of mesh in the region. Therefore, a multidisciplinary approach was planned for the patient with a bone anchor as a mesh fixation method. With a year follow up we did not observe a local hernia recurrence. CLINICAL DISCUSSION: Hernia itself is a multifactorial disease. As a anatomical defect, surgery is the only effective treatment. Our report brings a novel approach to a challenging case with many previous unsuccessful applications of conventional surgeries. Hence, we stimulate the multidisciplinary discussion for enhancing post operatory outcomes and a better point of care for the patient.

Pain during and after-hernioplasty in raquidian or locorregional anesthesia by locking peripheral nerves.

PURPOSE: To analyze pain scores after surgery in a group of patients submitted to inguinal hernia repair under peripheral nerve block with local or spinal anesthesia. METHODS: Fifty patients were divided into two groups (both with 25 patients each). In the first group the patients were submitted to herniorrhaphy under peripheral block and local anesthesia (LG) and in the other group the patients were submitted to the same procedure under spinal anesthesia (RG). The pain was assessed using the international visual analog pain scale at four different moments. The analysis cost of the procedure was performed using the hospital's average final cost, without including medical expenses. RESULTS: The groups were homogeneous in relation to the epidemiological and clinical features. There was no significant difference between the pain in the intraoperative period and in the return visit for both groups (p = 0.17 and p = 0.18). In the immediate postoperative period, both groups reported no pain at all. In general, the RG reported a greater pain score (16% for RG and 12% for LG). Complications were more frequent in patients submitted to spinal anesthesia (40% versus 8%) (p = 0.008). The surgical time was higher in the LG (39.3 ± 9.2 min) versus (28.7 ± 7.5 min) (p = 0.01). The average final cost of the procedure was US$ 100.98 for the LG and US$ 166.19 for the RG (p = 0.00). CONCLUSION: The inguinal hernioplastia under local anesthesia plus sedation is a safe method, with a low incidence of complications, great acceptance by patients and less expensive.

Colo-colonic intussusception due to large submucous lipoma: A case report.

INTRODUCTION: Intussusception in adult is rarely caused by idiopathic conditions. Main causes are inflammatory diseases, benign or malignant tumors and motility disorders. As a benign cause, lipomas appear as a particularly rare gastrointestinal intraluminal tumor occurring with highest incidence in the colon, mostly in the caecum and ascending colon. PRESENTATION OF CASE: A 57-year-old male patient was admitted at the surgical emergency in Belo Horizonte, with history of chronic and intermittent diffuse abdominal pain, associated with variations of his bowel habits and rare episodes of vomiting starting around 3days prior to admission. DISCUSSION: Intussusception is the cause of adult symptomatic bowel obstruction in 1% of the cases and its colocolonic occurrence represents 17% of all intestinal intussusceptions in adults. The reported case presents itself as even rarer considering its evaluation according to the epidemiological statistics of 1:5 men/women ratio and lipoma's most common location being the right colon. Intussusception and intestinal obstructions caused by intraluminal lipomas are not often described in the literature and its occurrence is directly related to its size, usually larger than 2cm diameter. The management of lipomatous intraluminal lesions of the colon is traditionally surgical, and it allows a selective resection, depending on the size of the tumor, length of intussusception, and the amount of inflammation. CONCLUSION: Patients with chronic abdominal symptoms and semi-obstruction caused by intussusception are rarely diagnosed before surgery unless there is a high index of suspicion. Colonoscopy contributes to diagnosis given that it provides direct visualization and biopsy.

Diagnostic usefulness of CD23 and FMC-7 antigen expression patterns in B-cell lymphoma classification.

CD23 and FMC-7 are normal B-cell antigens used during diagnostic immunophenotyping of suspected lymphoproliferative disorders, but the diagnostic usefulness of antigenic expression patterns of simultaneous 2-color staining and flow cytometric analysis has not been reported. We evaluated the FMC-7 and CD23 expression pattern in 201 cases of B-cell lymphoma from tissue biopsy specimens by multiparameter flow cytometry. The CD23-/FMC-7+ pattern was the most common pattern in large cell, mantle cell, and marginal zone lymphomas. The CD23 and FMC-7 antigen, along with the CD5 coexpression pattern, permitted accurate classification of all 71 cases of small lymphocytic, mantle cell, and marginal zone types of lymphoma. The widest variation of patterns was with follicular cell lymphoma, although most cases expressed the CD23 +/-/FMC-7+ pattern (+/-, partial or minor subset expression). The CD23 and FMC-7 antigen expression pattern was predictive of subtypes in more than 95% of lymphoma cases and could narrow the differential diagnosis in the remaining cases. We conclude the flow cytometric CD23/FMC-7 expression pattern achieved by dual staining facilitates accurate and reproducible classification of B-cell lymphomas and has diagnostic usefulness.

Insulin, chemotherapy, and the mechanisms of malignancy: the design and the demise of cancer.

The endogenous molecular biology of cancer cells involves autocrine and paracrine secretion of insulin and insulin-like growth-factors I and II, which subserve energy production and growth stimulation, respectively, in these cells. These activities confer on cancer its malignant potential, working as they do autonomously, free from higher levels of integrated control. Taking advantage of cancer's mechanisms of malignancy by employing exogenous insulin as a biologic response modifier, it is possible to potentiate the cytotoxic effects of chemotherapeutic agents for improved treatment of cancer. A synergy between certain membrane and metabolic effects of insulin on cancer cell molecular biology increases anticancer drug efficacy, and it does so with reduced doses of the drugs, enhancing their safety. This treatment strategy has been applied abroad over the last five decades with very promising clinical results.

[Fracture and intracoronary retention of a guidewire catheter in percutaneous transluminal angioplasty. A case report]. / Fratura e retenção intracoronariana de cateter guia de angioplastia transluminal percutânea. Relato de caso.

We present a rare coronary complication of angioplasty in which the steerable catheter was broken within the circumflex artery. Surgical removal of the fragment was possible and the patient had an uneventful recovery. Considerations on this serious problem, its possible causes, prevention and management are made.

[Coronary angioplasty in chronic occlusion of 9 and half years. Use of laser with a new catheter for recanalization]. / Angioplastia coronária em oclusão crônica de nove anos e meio. Utilização do laser com um novo cateter para recanalização.

A chronic total occlusion lasting 9.5 years, was successfully treated with a Prima (TN) Laser catheter, of Spectranectics. The authors report a case of a fifty seven year old male that suffered an inferior myocardial infarction 9.5 years ago. Although the morphological characteristics of the lesion seemed easy to pass through the obstruction with the guide wire, the balloon dilatation was not possible because of the hardness of a chronic lesion lasting that long. The intervention was concluded successfully in another opportunity using the laser catheter with certain facility. This case, reported as the first one in Latin America, rises new possibilities and increases the success rate of coronary angioplasty of total chronic occlusions. We hope that in the following cases we will be able to reach the same result, widening the indications of coronary angioplasty.

[Dextrocardia in situs inversus totalis with obstructive coronary disease. Its treatment by coronary angioplasty by the brachial approach]. / Dextrocardia em "situs inversus totalis" com doença obstrutiva coronária. Tratamento pela angioplastia coronária por via braquial.

Dextrocardia in "situs inversus totalis" with obstructive coronary disease is a rare clinical situation, with few cases treated by coronary angioplasty using the femoral approach being reported. In this report we describe the case of a 61-year-old male patient who underwent successful dilatation of two arteries by the brachial approach. We discuss technical aspects related to the procedure, which may be easily performed when proper equipment is available.

[Excimer-laser angioplasty for the treatment of restenosis after Wiktor and Gianturco-Roubin stent placement. A new therapeutic alternative]. / Angioplastia com excimer-laser para o tratamento de reestenose pós implante de stent de Wiktor e Gianturco-Roubin. Uma nova alternativa de tratamento.

We report the use of excimer-laser angioplasty for the treatment of Wiktor and Gianturco-Roubin in-stent restenosis of in two patients. Case 1-a 48-year-old man presented unstable angina five months after Wiktor stent was deployed in right coronary artery. Cardiac catheterization revealed stenosis (95%) within the stent. Case 2-a 65-year-old man presented stable angina four months after Gianturco-Roubin stent was deployed in left anterior descending artery. Cardiac catheterization revealed stenosis (80%) within the stent. Excimer-laser angioplasty within the stent reduced the stenosis to 19% and 30%, respectively. The patients recovered and currently, six months post-procedure, are free of chest pain, and cardiac catheterization revealed stenosis to 30% and 35%, respectively, within the stent. Therefore, the procedure was an effective means of treating restenosis after coronary stent placement, and a prospective comparison of excimer-laser angioplasty and other management alternatives to in-stent restenosis is needed.

[Analysis of the composition and spatial disposition of atherosclerotic plaques localized in epicardial coronary artery bifurcations in adults]. / Análise da composição e disposição espacial de placas ateroscleróticas localizadas em bifurcações das artérias coronárias epicárdicas de adultos.

PURPOSE: To analyze macro and microscopic features of atherosclerotic plaques located in bifurcation of coronary arteries, defining their spatial disposition in those sites. METHODS: We studied 38 bifurcations of coronary arteries of patients whose cause of death was related to coronary artery disease. Histologic sections of 0.5mm were sequentially made from the main artery to the secondary branches. They were stained with hematoxilin-eosin technique. Histological analysis evaluated: a) morphologic composition of the plaques, b) degree of obstruction and c) plaque's disposition. RESULTS: a) Plaque's composition: fibrolipid plaques constituted 80% of the cases and mingled focal atrophy of the media at the base of the plaque in 61% with spots of total destruction and rupture of the elastic layers in 30%; b) degree of obstruction: ranged from 20% to 95%, with average 60 +/- 28%; c) disposition of plaques: we verified morphologic variation along the plaque, most of them (71%) being eccentric at bifurcation and not reaching the beginning of flow divider walls. CONCLUSION: Atherosclerotic plaques located in bifurcation of coronary arteries of adults are often fibrolipid plaques, eccentric, and their spatial disposition on those sites spare the beginning of the inner walls, reaching the outer walls.

[Analysis of elastic retraction in the 1st 15 minutes after coronary balloon angioplasty]. / Análise da retração elástica nos primeiros 15 minutos após angioplastia coronária por cateter balão.

PURPOSE: To determine the time course of elastic recoil (ER) in the first 15min after successful percutaneous transluminal coronary angioplasty (PTCA). METHODS: One hundred and fifty four patients, with stable or unstable angina were successfully submitted to PTCA. Coronary angiography was undertaken shortly after balloon deflation and repeated 5, 10 and 15 min thereafter. Quantitative coronary angiography was performed with the aid of an eletronic caliper. We calculated the minimal luminal diameter (MLD) and elastic recoil in all angiograms. RESULTS: The average artery's reference diameter was 3.09 +/- 0.61mm and the maximal balloon diameter was 2.95 +/- 0.52mm. MLD before the procedure was 0.65 +/- 0.42mm reaching 2.23 +/- 0.55mm immediately after dilatation (p < 0.0001), and decreasing to 2.09 +/- 0.47mm at 5min (p < 0.0001), 2.01 +/- 0.47 at 10min (p < 0.0001) and to 1.91 +/- 0.56mm at 15min (p < 0.0001). ER increased during the 1st 15min after PTCA, averaging 34.29 +/- 20.40%. In the group of patients whose balloon/artery relationship was < or = 1, the total ER was 0.90 +/- 0.74mm at 15min and 1.20 +/- 0.50mm when the ratio was > 1 (p < 0.0001). We noted that ER in the group of patients with residual stenosis ranging from 30 to 50% at the immediate angiogram after PTCA was greater than in the group whose residual stenosis was less than 30%. CONCLUSION: ER is a dynamic and progressive phenomenon taking place within the 1st 15 min after a successful PTCA. Total ER was 34.29 +/- 20.40% at 15min and was greater when balloon/artery relationship was > 1. Residual stenosis ranging from 30 to 50% in the control immediately after the procedure is a predictive factor of greater ER in the 15min following PTCA.

[Coronary artery perforation with rotational coronary atherectomy]. / Perfuração de artéria coronária com rotablator.

The authors describe a rare case of circumflex coronary artery perforation during rotational coronary atherectomy complicated with cardiac tamponade and good outcome. The possible causes of perforation are discussed and the burr oversize (burr/artery ratio was 0.58) was refused. Shortening and artery plicature (accordeon effect) might have been the cause of this event. Quantitative measurement was made in order to strengthen this hypothesis. It is emphasized the importance of selecting lesions that should be submitted to rotational coronary atherectomy.

[Sublingual isosorbide-5 mononitrate during coronary arteriography. Comparison with sublingual nitroglycerin]. / Ação do mononitrato-5 de isossorbida sublingual durante cinecoronariografia. Comparação com o uso de nitroglicerina sublingual.

PURPOSE: To evaluate the effect of sublingual isosorbide-5 mononitrate (ISMN) and nitroglycerin (NTG) on luminal diameter of epicardial coronary arteries, mean arterial pressure and deleterious effects. METHODS: Fifty patients were submitted to cardiac catheterization and coronary arteriography, at baseline, and 5 min after sublingual administration of ISMN, group A (GA) or NTG, group B (GB). RESULTS: Reference vessel diameter increased in both groups, without statistical significance. In GA and GB, a decrease (1.66 mmHg) and an increase (0.79 mmHg) in mean arterial pressure, respectively, were demonstrated (p = 0.123). There were no deleterious effects with the use of these drugs. CONCLUSION: Sublingual ISMN is an alternative to administration of NTG during coronary arteriography, and represents a therapeutic alternative to ischemic heart disease treatment.

[Laser coronary angioplasty. Critical analysis of the first patients]. / Angioplastia coronária com o uso do laser. Análise crítica dos primeiros pacientes.

PURPOSE: To evaluate the success rate and complications, as well as the technical difficulties involved catheter laser coronary angioplasty, making evident the unsuccessful cases. METHODS: Twenty eight patients were treated with laser from August to November, 1993. The treatment was complemented with balloon angioplasty. Lesions were complex: 10 (36%) were type B and 18 (64%), type C. Concerning the obstruction grade, 18 (64%) were > or = 95%. Laser generator CVX 300(TM) Spectranectics as well as Extreme(TM) and Vitesse(TM) catheters with 1.4, 1.7 and 2.0mm in diameter, concentric and excentric, were used. Laser procedure success was defined as a reduction > 20% in the obstruction grade. The procedure success was attended when the residual stenosis was < 50% after a 15-minute observation, after balloon complementation. RESULTS: The unsuccess rate with laser catheter (Lc) was 34% (10 lesions) of which 3 cases were solved by other methods, 5 were not successful because of anatomic difficulties in surpassing the lesion and, in the two others the success criterium in the reduction of the obstruction grade of the coronary artery was not achieved, although the lesion surpassing was possible with the use of balloon catheter. The final success reached 89% (21 lesions). The procedure complications were a case of thrombosis, a perforation accompanied by a myocardial infarction and another myocardial infarction (non-Q wave), all with good outcome. CONCLUSION: The use of laser in the treatment of coronary artery obstructive lesions is a viable method. Nonetheless, more experience is necessary to demonstrate its actual value, optimizate the results and may be reduce restenosis rate.

[Prevalence of residual shunt after closure of patent ductus arteriosus with Rashkind umbrellas]. / Prevalência do shunt residual após fechamento de canal arterial persistente com umbrellas de Rashkind.

PURPOSE: To determine the prevalence of residual left-to-right shunt in patients submitted to closure of patent ductus arteriosus with use of Rashkind double-disc ductal occluding device, analyzing predictive factors that determine short and long-term prevalence of residual shunt. METHODS: Thirteen patients were submitted to percutaneous closure of patent ductus arteriosus with use of Rashkind double-disc device. Ten patients were male with mean age of 5.7 years. A 12mm diameter device was used in 7 cases and a 17mm device in the remaining six patients. All patients had clinical, radiological and echocardiographic follow up, after 24h, 1 month, 6 months and one year after the procedure. Morphology and length of the ductus arteriosus and the presence of residual shunt after 15 min, 24h and one year after the procedure, were correlated. RESULTS: In one case, embolization of the device to the pulmonary artery determined the in success of the procedure. Residual shunt was present in 75% of the patients after 15 min of the procedure, in 33.3% after 24h, in 25% after 1 month and 6 months and in 16.6% after 1 year. The most important and isolated predictive factor leading to a high prevalence of residual shunt after 24h and after 1 year of the procedure was the presence of ductus arteriosus diameter > or = 4.5mm at the site of its insertion in the pulmonary artery. CONCLUSION: Prevalence of residual left-to-right shunt decreases over the time, with a low incidence after one year follow-up. A higher incidence of residual shunt at 24h and 1 year after the procedure occurred in the cases where the diameter of the ductus arteriosus was > or = 4.5mm, at the site of its insertion in the pulmonary artery.