[Teres ligament hemangioma: laparoscopic approach]. / Hemangioma del ligamento redondo: resección laparoscópica.

Hemangiomas are benign vascular tumors, whose origin comes from the embryonic mesodermal tissue remains. The liver is the most common location. Its location in the teres ligament is extremely rare. This is a 59 years old male admitted because of episodes of epigastric pain for six months. A CT scan and MRI demostrated a 2 cm diameter lesion located near the Teres ligament. Laparoscopic resection was performed. Hemangiomas are the most common benign solid tumors located in the liver. They represents 73% of all benign liver tumors. MRI is the imaging of greater certainty for diagnosis. The Teres ligament (ligamentum teres hepatis) is a fibrous cord resulting in obliteration of the umbilical vein. The location of hemangiomas in this region is extremely rare but should be considered and should make the differential diagnosis with a pedicled hepatic hemangioma or gastointestinal stromal tumors.

Single Port Laparoscopic Gastrostomy: description of a technique and initial experience.

INTRODUCTION: Since the first classic descriptions of surgical gastrostomies for feeding by supra-umbilical medial incisions, patients were operated under general anesthesia, with prolonged time of surgery; these were patients in poor health status, undernourished due to inadequate intake or to neurological or tumor involvement, with prolonged hospitalization, both for the recovery of the intestinal motility as well as for the recovery of post-surgical wounds. Therefore, we describe a new minimally invasive technique as an alternative to the percutaneous or endoscopic gastrostomy, in patients where we are not allowed to place a nasogastric tube to insufflate the stomach. This is mostly seen in patients with tumors, which cause obstruction. MATERIAL AND METHODS: Between July 2012 and June 2013, 8 patients underwent a single port laparoscopic gastrostomy. Five were females, mean age: 77 years (range: 67-87). In all the patients, it was impossible to place a nasogastric tube, due to obstructive tumor. RESULTS: The mean time of the procedure was 45 minutes. Seven patients underwent tolerance of dextrose 10% through the catheter after 12 hours and one 24 hours after the procedures. Enteral feeding was indicated after the dextrose 10% tolerance was performed. No complications related to the procedure were observed. DISCUSSION: Currently, the gold standard technique to perform a gastrostomy is the percutaneous or endoscopic approach. In patients with head and neck tumors, when it is not possible to insert a nasogastric tube to insufflate the stomach, a laparoscopic gastrostomy would be indicated. We describe a new technique, step by step, to perform less invasive laparoscopic surgery by a single port laparoscopic gastrostomy. CONCLUSION: The diameter created is the same as the one performed with an open technique, but in this case, with a minimally invasive approach, that allows us to start feeding the patient with a high quality of feeding, because of the wider lumen.

Total gastrectomy due to ferric chloride intoxication.

INTRODUCTION: The ferric chloride intoxication is frequently caused by accident. Its toxicity is generally underrated, which can lead to fatal evolution or irreversible consequences. In this case, the caustic condition of the substance is related to the toxic properties of iron. CASE PRESENTATION: A 36-year-old male patient arrives by ambulance indicating sensory deterioration. He presents erosive injuries in the buccal cavity and in the oropharynx, brownish teeth and metabolic acidosis. Toxicology tests and ferritin blood dosage are requested, which show a result from 1400 mg/dl. The symptoms are interpreted as acute iron intoxication. Due to the unfavorable evolution of his condition, an abdominal and pelvic CT scan are performed, which show extensive pneumoperitoneum and free fluid in the abdominal cavity. An exploratory laparotomy, a total gastrectomy with esophagostomy and feeding jejunostomy, washing and drainage due to perforated gastric necrosis caused by caustic ingestion are performed. DISCUSSION: In our country, there is a high rate of intoxication caused by iron compounds, although it is not statistically measured. Nevertheless, the ferric chloride intoxication is extremely infrequent. The ingestion of this product leads to complications, which are associated with the iron concentration and its condition as a caustic agent. CONCLUSIONS: The surgical indications in the presence of intoxication caused by iron compounds are: stomach evacuation of iron, gastric necrosis, perforation or peritonitis and stenosis. Early or prophylactic gastrectomy is contraindicated. However, if complications that require immediate surgical intervention arise, there should be no hesitation and the corresponding procedure should be performed.

[Gastric Bypass versus Sleeve gastrectomy: comparison between type 2 Diabetes weight loss and complications. Review of randomized control trails]. / Bypass gástrico vs manga gástrica: comparación de resultados sobre diabetes tipo 2, descenso de peso y complicaciones. Revisión de ensayos clínicos controlados aleatorizados.

INTRODUCTION: Obesity today is a major health problem worldwide and the leading health problem in Western countries because it is associated with multiple comorbidities that increase the mortality of these patients. MATERIAL AND METHODS: A review of the literature was done in PubMed (Medline) and Cochrane Library of randomized controlled trials comparing gastric bypass with sleeve gastrectomy in the treatment of obesity and type 2 diabetes mellitus (T2DM). Eighteen papers were found, of which eleven met the initial inclusion criteria. DISCUSSION: The variables analyzed to determine the superiority of one technique over the other were: the percentage ofexcess BMI lost (% EIMCP), the percentage of excess weight loss (% EPP), BMI at the end of the study, lost Kg and the percentage of weight lost. Regarding the control of T2DM fasting glycemia, the glycosylated hemoglobin (HbAlc), whether or not oral agents or insulin were considered. CONCLUSION: No highlighting differences in results that can be obtained with RYGB and MG to control obesity and T2DM. Either method achieves excellent results, even surpassing those obtained with dietary, pharmacological and behavioral treatment.

[Treatment of bile duct stones by laparoscopy, endoscopy or combined approaches]. / Tratamiento de la litiasis coledociana mediante cirugía laparoscópica, endoscopía o combinado.

INTRODUCTION: Gallstones are a very common disease in our area, with a prevalence of 21.9%. Among the most common complications, choledocholithiasis is associated in about 3% to 10% of cases. The treatment may be performed by minimally invasive laparoscopy, endoscopy or a combination of both. There is no current consensus on what is the best strategy for treatment. We aimed to review the evidences of highest quality available, comparing two therapeutic strategies for cholelithiasis. Choledocholithiasis is divided into that in patients who underwent a cholecystectomy and that in patients with associated cholelithiasis. In the first group we have three subgroups: a) patients in whom gallstones remained intraoperatively, b) patients with bile duct lithiasis and biliary drainage, and c) patients with bile duct lithiasis without biliary drainage. In the first case can be performed a laparoscopic treatment at one or two times; in the second, a transfistular approach; and in the third, an endoscopic treatment. If the endscopic tretament fails, percutaneous or laparoscopic reoperation can be done. The treatment of a cholelithiasis associated with choledocholithiasis can be performed by laparoscopy, endoscopy or a combination of both. We conclude that the innovation of minimally invasive techniques has revolutionized the management of bile duct stones. The treatment in one time is possible in patients with adequate operative risk and in the hands of trained surgeons. Multidisciplinary approach is mandatory, according to the diagnostic and therapeutic method, depending on the means available in each institution.

[Porcelain gallbladder: a clinical case and a review of the literature]. / Vesícula de porcelana. Caso clínico y revisión de la literatura.

Porcelain bladder is defined as calcification of the gallbladder wall. It is a rare condition and is seen in 0.06% to 0.8% of cholecystectomies. It origin is still unknown. We report two cases of patients with a porcelain gallbladder. One case is a 60 year-old male patient who was seen due to having biliary symptoms. The diagnosis was made by ultrasound and computed tomography, and he was surgically intervened by performing a partial cholecystectomy. The histopathology reported a gallbladder wall with sclerohyalinosis and dystrophic calcification foci. The other case is a 98 year-old female patient, whose form of presentation was incidental given that she suffered from symptoms of an intestinal obstruction. A cholecystectomy was performed with a good post-surgical outcome. A series published in between 1950 and 1960 show that the porcelain bladder can be frequently observed in patients with cancer of the gallbladder, although this relationship is currently being rejected. The reason why these cases are being presented is because of their low incidence and the controversy over what treatment to use, due to its association with gallbladder cancer.

Chronic Gastric Dilation-Surgical Management.

Background: Chronic dilation of the gastric remnant is a rare complication, although it can be serious. It is due to an exaggerated distension of the gastric remnant after a Roux-en-Y gastric bypass (RYGB). Clinical suspicion and computed tomography (CT) are essential for its diagnosis. Its treatment is by means of a decompressive gastrostomy, which can be percutaneous or surgical, an option that can be carried out in certain patients. We present a clinical case of chronic dilation of the gastric remnant and its laparoscopic surgical resolution. Methods: We present a clinical case of a 67-year-old patient who underwent a RYGB. An abdominal CT scan showed chronic dilation of the gastric remnant. A laparoscopic biopsy and a laparoscopic-assisted percutaneous gastrostomy were performed. Conslusion: The combined percutaneous laparoscopic approach is a good option for cases of chronic gastric dilations of unknown origin, allowing to discover and treat its causes.

Revisional Surgery: Aphagia After Gastric Bypass.

Background: Gastric bypass is one of the most widely performed bariatric procedures worldwide and continues to be the gold standard in obese patients with metabolic disorders.1 Regarding the complications, these can appear early or late, the most frequent of the latter being anastomosis stenosis, especially the gastrojejunal (G-J) stenosis. The first treatment option in stenosis is the endoscopic approach, but in cases wherein it fails or the diagnosis is kinking, revisional surgery should be performed. Methods: We describe the technique, step by step, we use to perform a very complex revisional surgery in a patient with aphagia after gastric bypass. Results: This is the case of a 38-year-old female patient who underwent laparoscopic adjustable gastric band in 2011; due to her poor tolerance, a laparoscopic gastric bypass was done. She began with vomiting and gastroesophageal reflux with remarkable symptoms. Diagnosis of stenosis of the jejunojejunal anastomosis of the Roux-en-Y was made and two surgeries were done to treat it. Later the patient referred aphagia and a kink of the gastrojejunal (G-J) anastomosis were observed in the gastrointestinal series. We decided to do a revisional surgery and we describe it step by step in this article. Conclusion: The G-J anastomosis stenosis is the most frequent late complication. Also kinking has to be considered strongly when aphagia or symptoms of obstruction are present. If endoscopic treatment for stenosis or cases of kinking is unsuccessful and fails, then revisional surgery should be considered.

N-SLEEVE GASTRECTOMY: AN OPTION FOR OBESITY AND GERD.

BACKGROUND: Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that's why some patients have reflux after sleeve. AIM: To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve. METHOD: In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care. RESULTS: This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after. CONCLUSION: N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.

Conventional Laparoscopic Appendectomy Versus Single-Port Laparoscopic Appendectomy, a Multicenter Randomized Control Trial: A Feasible and Safe Alternative to Standard Laparoscopy.

Background: Acute appendicitis represents one of the main causes of surgical emergencies. It can be approached as open appendectomy or laparoscopic appendectomy (LA). LA uses different modalities, such as conventional laparoscopic appendectomy (CLA) or single-port laparoscopic appendectomy (SPLA). The aim of this work is to compare the results of CLA versus SPLA in patients diagnosed with Acute Appendicitis. Materials and Methods: A comparative multicenter prospective study of patients undergoing LA with a clinical diagnosis of acute appendicitis was presented. They were divided into two groups (CLA group and SPLA group). Results: A total of n = 147 patients were included (72 CLA and 75 SPLA). Preoperative and intraoperative times were shorter for patients undergoing CLA (P = .002; P = .068). Postoperative and reinsertion time was lower for SPLA (P = .000; P = .0004). There were no differences in postoperative complications. The type of approach showed statistically significant differences with respect to pain within the first 12 hours of the postoperative period, as well as at discharge, while no differences were observed in relation to cosmetic satisfaction when the two approaches were compared. Conclusion: SPLA technique presented less intraoperative time, shorter time of labor reinsertion, and less postoperative pain. There were no statistically significant differences in postoperative complications.

Most common robotic bariatric procedures: review and technical aspects.

Since its appear in the year 1997, when Drs. Cadiere and Himpens did the first robotic cholecystectomy in Brussels, not long after the first cholecystectomy, they performed the first robotic bariatric procedure. It is believed that robotically-assisted surgery's most notable contributions are reflected in its ability to extend the benefits of minimally invasive surgery to procedures not routinely performed using minimal access techniques. We describe the 3 most common bariatric procedures done by robot. The main advantages of the robotic system applied to the gastric bypass appear to be better control of stoma size, avoidance of stapler costs, elimination of the potential for oropharyngeal and esophageal trauma, and a potential decrease in wound infection. While in the sleeve gastrectomy and adjustable gastric banding its utility is more debatable, giving a bigger advantage during surgery on patients with a very large BMI or revisional cases.

Late surgical complications after gastric by-pass: a literature review.

INTRODUCTION: Gastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones. METHOD: Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS: There were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula. CONCLUSION: Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.

Early surgical complications after gastric by-pass: a literature review.

INTRODUCTION: Gastric bypass is today the most frequently performed bariatric procedure,but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the early ones. METHOD: Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS: There were selected 26 studies that matched the headings. Early complications included: anastomotic or staple line leaks, gastrointestinal bleeding, intestinal obstruction and incorrect Roux limb reconstruction. CONCLUSION: Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention.

N-sleeve gastrectomy: an option for obesity and gerd / N-gastrectomia vertical: uma opção para obesidade associada à doença do refluxo gastroesofágico

ABSTRACT Background: Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that's why some patients have reflux after sleeve. Aim: To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve. Method: In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care. Results: This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after. Conclusion: N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.

RESUMO Racional: A obesidade representa ameaça crescente à saúde da população em todo o mundo. A gastrectomia por laparoscopia induz alteração do ângulo esofagogástrico devido à própria técnica, hipotonia do esfíncter esofágico inferior após secção de fibras musculares da junção, diminuição do volume gástrico e, consequentemente, aumento da pressão intragástrica; é por isso que alguns pacientes têm refluxo após a gastrectomia vertical. Objetivo: Descrever uma técnica e resultados preliminares da gastrectomia vertical com fundoplicatura a Nissen, a fim de diminuir o refluxo após ela. Método: No artigo atual, descrevemos a técnica passo a passo, principalmente focada na criação da válvula e seu cuidado. Resultados: Este procedimento foi aplicado em um caso de mulher com IMC 45 de 53 anos com DRGE. Foi realizada endoscopia demonstrando hérnia hiatal e cinco pólipos benignos. A gastrectomia vertical com Nissen foi realizada devido à DRGE, à hérnia hiatal e aos múltiplos pólipos no estômago. Ela tolerou bem o procedimento e recebeu alta sem intercorrências 48 h depois. Conclusão: A N-gastrectomia vertical (N-sleeve) é alternativa viável e segura em pacientes obesos com refluxo e hérnia hiatal quando não é indicado o desvio gástrico em Y-de-Roux.

Late surgical complications after gastric by-pass: a literature review / Complicações cirúrgicas tardias após bypass gástrico: revisão da literatura

INTRODUCTION: Gastric bypass is today the most frequently performed bariatric procedure, but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the late ones. METHOD: Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS: There were selected 35 studies that matched the headings. Late complications were considered as: anastomotic strictures, marginal ulceration and gastrogastric fistula. CONCLUSION: Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention. .

INTRODUÇÃO: O bypass gástrico é hoje o procedimento bariátrico mais realizado, mas, apesar disso, várias complicações podem ocorrer com variada morbimortalidade. Provavelmente todos os cirurgiões bariátricos conhecem essas complicações, mas como a cirurgia bariátrica continua a se espalhar, o cirurgião geral deve estar familiarizado com essas complicações e seu manuseio. As complicações do bypass gástrico podem ser divididas em dois grupos: as precoces e tardias, tendo em conta o período de duas semanas após a operação. Este artigo irá focar as tardias. MÉTODO: Foi realizada revisão da literatura utilizando as bases Medline/PubMed, Cochrane Library, SciELO, e informações adicionais sobre sites institucionais de interesse cruzando os descritores: bypass gástrico AND complicações; seguimento AND complicações; complicações pós-operatórias AND anastomose, Roux-en-Y; obesidade AND complicações pós-operatórias. A língua usada para a busca foi o inglês. RESULTADOS: Foram selecionados 35 estudos que combinavam com os descritores. As complicações tardias foram consideradas como: estenose de anastomose, ulceração marginal e fístula gastrogástrica. CONCLUSÃO: O conhecimento sobre as estratégias de como reduzir o risco e incidência das complicações deve ser adquirido ao longo do tempo, e cada cirurgião deve estar familiarizado com essas complicações, a fim de reconhecê-las precocemente e realizar a melhor intervenção. .

Early surgical complications after gastric by-pass: a literature review / Complicações cirúrgicas precoces após bypass gástrico: revisão da literatura

INTRODUCTION: Gastric bypass is today the most frequently performed bariatric procedure,but, despite of it, several complications can occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to it and its management. Gastric bypass complications can be divided into two groups: early and late complications, taking into account the two weeks period after the surgery. This paper will focus the early ones. METHOD: Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search language was English. RESULTS: There were selected 26 studies that matched the headings. Early complications included: anastomotic or staple line leaks, gastrointestinal bleeding, intestinal obstruction and incorrect Roux limb reconstruction. CONCLUSION: Knowledge on strategies on how to reduce the risk and incidence of complications must be acquired, and every surgeon must be familiar with these complications in order to achieve an earlier recognition and perform the best intervention. .

INTRODUÇÃO: O bypass gástrico é hoje o procedimento bariátrico mais realizado, mas, apesar disso, várias complicações podem ocorrer com variada morbimortalidade. Provavelmente todos os cirurgiões bariátricos conhecem essas complicações, mas como a cirurgia bariátrica continua a se espalhar, o cirurgião geral deve estar familiarizado com essas complicações e seu manuseio. As complicações do bypass gástrico podem ser divididas em dois grupos: as precoces e tardias, tendo em conta o período de duas semanas após a operação. Este artigo irá focar as precoces. MÉTODO: Foi realizada revisão da literatura utilizando as bases Medline/PubMed, Cochrane Library, SciELO, e informações adicionais sobre sites institucionais de interesse cruzando os descritores: bypass gástrico AND complicações; seguimento AND complicações; complicações pós-operatórias AND anastomose, Roux-en-Y; obesidade AND complicações pós-operatórias. A língua usada para a busca foi o inglês. RESULTADOS: Foram selecionados 26 artigos que combinavam com os descritores. As complicações imediatas foram: fístula na linha de grampeamento, sangramento gastrointestinal, obstrução intestinal e reconstrução incorreta da alça em Roux. CONCLUSÃO: O conhecimento sobre as estratégias de como reduzir o risco e incidência das complicações deve ser adquirido ao longo do tempo, e cada cirurgião deve estar familiarizado com essas complicações, a fim de reconhecê-las precocemente e realizar a melhor intervenção. .

Apendicectomía laparoscópica por incisión única con instrumental recto, experiencia inicial / Single-access laparoscopic appendectomy with straight instrument; initial experience

Introducción. La apendicitis aguda es la enfermedad abdominal quirúrgica más frecuente, se reportan alrededor de 250.000 nuevos casos al año. Material y métodos. Se llevó a cabo un estudio prospectivo, descriptivo y de cohorte. Entre abril y diciembre de 2012 se practicaron 43 apendicectomías laparoscópicas, 25 por vía laparoscópica convencional mediante la utilización de 3 trocares. En cuatro procedimientos por incisión única, se requirió la colocación de uno y dos puertos accesorios, por presentarse peritonitis generalizada. Catorce fueron intervenidos mediante cirugía laparoscópica por incisión única. Seis fueron de sexo femenino y ocho de sexo masculino. La media de edad fue de 20,07 años, con un rango de 15 a 27 años. Resultados. Los pacientes consultaron por dolor abdominal en la fosa ilíaca derecha, con una evolución de 24 a 72 horas. El diagnóstico intraoperatorio fue apendicitis congestiva en un paciente, apendicitis flegmonosa en nueve, apendicitis gangrenosa en tres y apendicitis gangrenosa con peritonitis localizada en uno. La duración promedio de la cirugía fue de 54,28 minutos (rango, 25 a 75). La intensidad del dolor a las 24 horas medido con escala visual análoga fue de 2,4 en promedio (rango de 1 a 8). El promedio de internación fue de 1,91 días (1 a 6). El grado promedio de satisfacción con el resultado cosmético fue de 9,5, con un rango de 8 a 10. Conclusiones. Esta variante técnica es segura, efectiva, reproducible y presenta todas las ventajas de la cirugía laparoscópica. El resultado cosmético pareciera ser superior cuando se compara con el de la cirugía laparoscópica convencional multipuerto.

Introduction: Acute appendicitis is the most common abdominal surgical entity, with 250,000 new cases being annually reported in the USA. Material and methods: This is a prospective, descriptive, and cohort study, of 43 laparoscopic appendectomies that were performed in the period April and December of 2012, 25 by the conventional three trocar approach. In four cases in which the initial technique was the single access laparoscopy, it became necessary to use one or two accessory ports because of peritonitis. Fourteen were performed by the single access approach, six females and eight males, with an average age of 20.6 years ranging between 15 and 27 years. Results: Patients were admitted because of 24 to 72 hours of abdominal pain over the right lower quadrant. Intraoperative diagnosis was congestive acute appendicitis in one patient, phlegmonous appendicitis in nine, gangrenous appendicitis in three, and gangrenous appendicitis with generalized peritonitis in one. Average operating time was 54.28 minutes (ranging 25 to 75 minutes). The average pain scale (from 1 to 10) after 24 hours was 2.42 (range 1 to 8). The average hospital stay was 1.91 days, ranging from 1 to 6. Degree of satisfaction with the cosmetic result was 9.5, ranging between 8 and 10. Conclusions: This novel technique is safe, effective and reproducible and has all the advantages of laparoscopic surgery. Cosmetic result appears superior when compared with conventional laparoscopic multiport surgery.

Mediastinitis necrotizante descendente: dieciseis años de experiencia / The descending necrotizing mediastinitis

Antecedentes: La mediastinitis necrotizante descendente es una entidad poco frecuente de alta mortalidad que se origina en procesos sépticos orofaríngeos o cervicales mal drenados. El pasaje de material infectado se realiza a través del espacio parafaríngeo, y de allí por el espacio retrovisceral hacia el mediastino posterior.Objetivos: Definir los parámetros para diagnosticar en forma temprana esta afección y lograr así instaurar rápidamente la conducta quirúrgica agresiva que nos permita disminuir la elevada tasa de mortalidad de esta severa complicación. Lugar de aplicación: Hospital nacional universitario. Diseño: Retrospectivo y descriptivo. Población: Práctica hospitalaria. Material y método: Entre 1995 y 2011 fueron tratados 12 pacientes con mediastinitis necrotizante (7 hombres y 5 mujeres). El foco fue absceso dentario en 9 y absceso amidgalino, absceso pos-fractura de maxilar y mastoiditis, en 1 caso respectivamente. Todos presentaron edema cervical, fiebre y dolor y fueron estudiados con radiología convencional y TAC cervicotorácica de inicio. El tiempo de demora entrela primera consulta y la atención en nuestro hospital fue de más de 72 hs en el 75% de los pacientes. Todos fueron operados por un doble abordaje, cervical y torácico. A 4 pacientes se les realizó abordaje torácico bilateral.Resultados: Las complicaciones fueron: distres respiratorio en 7, bronconeumonía en 3, hemorragia cervical e infección urinaria en1. Fueron reoperados 4 paciente. La mortalidad fue del 33% (4 de 12 pacientes).Conclusión: Si bien la mediastinitis necrotizante descendente es una entidad rara, su gravedad obliga a considerarla como complicaciónante todo absceso cervical no drenado. La TAC cervicotorácica en estos pacientes, sumada a una conducta terapéutica quirúrgica agresivason las claves para un diagnostico precoz y un tratamiento efectivo.

Tumor de Evans perineal / Evans perineal tumor

INTRODUCCION. El tumor de Evans es un sarcoma fibromixoide de bajo grado, poco común, originado en los tejidos blandos. La recurrencia local es habitual y las metástasis a distancia muy poco frecuentes. La localización perineal es extremadamente rara. La mayoría de los datos sobre ellos provienen de comunicaciones individuales y no se conoce mucho sobre su etiología, patogenia y pronóstico. Se presenta un caso de sarcoma de Evans perineal, con revisión de la literatura. LUGAR DE APLICACIÓN. Hospital Nacional Profesor Alejandro Posadas, Buenos Aires, Argentina. CASO CLINICO: Mujer de 49 años. En 1993 durante parto vaginal se palpa tumoración vulvoperineal; la paciente abandona el seguimiento. Concurre en 2008 a nuestro servicio presentando una gran tumoración perineal abscedada. Se realizan estudios imagenológicos confirmando su localización extrarectal. Se realizan biopsias no significativas. Se realiza exéresis tumoral por vía perineal con reparación esfinteriana y colostomía sigmoidea de protección. Evoluciono sin complicaciones. RESULTADOS. El protocolo de la anatomía patológica informó sarcoma fibromixoide de bajo grado (Tumor de Evans). A dos años de seguimiento sin signos de recidiva local ni metástasis a distancia. CONCLUSIONES. El tumor de Evans es una neoplasia extremadamente rara y más aun la localización perineal. El tratamiento de elección es la exéresis quirúrgica. El pronostico parecería estar determinado por la recidiva local.

BACKGROUND: Evans tumor is a rare, low-grade fibromyxoid tumor which originates in the soft tissues. Local recurrence is common and distant metastases are infrequent. Perineal localization is extremely rare. Most of the data about them are individual case reports and not much is known about their etiology, pathogenesis and prognosis. A case of a perineal Evans tumor is presented, together with a literature review. CASE REPORT: A 49 year old woman, in whom in 1993 during a vaginal delivery a vulvoperineal mass is palpated; the patient is lost in the follow-up. In 2008 she comes to our Department presenting a large perineal tumor and abscess. Imaging studies are carried out confirming its extra-rectal localization. Biopsies are taken and are indeterminate. The tumor is excised through the perineal route. The patient had no complications. RESULTS: The pathology report informs low grade fibromyxoid sarcoma (Evans tumor). She is two years in follow-up without signs of neither local recurrence nor distant metastases. CONCLUSIONS: An Evans tumor is an extremely rare neoplasm, and furthers more in a perineal localization. The treatment of choice is surgical excision. The prognosis is apparently determined by local recurrence.