Assistência ao parto pélvico / Breech birth assistance

É imprescindível retomar o ensino da versão cefálica externa e das manobras tocúrgicas no parto pélvico vaginal, tanto em litotomia quanto na posição vertical. A adoção de protocolos rígidos para o parto pélvico vaginal planejado correlaciona-se com taxa de sucesso de aproximadamente 70% e taxas de resultados adversos inferiores a 7%. A morbimortalidade fetal e neonatal é semelhante à de cesárea planejada. Gestantes elegíveis para o parto pélvico vaginal devem concordar com a via de parto, possuir baixo risco de complicações e ser assistidas por profissionais com experiência em parto vaginal de apresentações anômalas e suas manobras obstétricas. Cesariana prévia e prematuridade entre 32 e 36 semanas não são contraindicações absolutas ao parto pélvico vaginal, devendo ser individualmente avaliadas na decisão da via de parto. Neonatologistas devem estar presentes no nascimento de fetos pélvicos, e um exame neonatal completo deve ser realizado. A rotação posterior do dorso fetal, o prolapso de cordão umbilical, a deflexão dos braços e/ou do polo cefálico e o encarceramento da cabeça derradeira são as principais distocias relacionadas à assistência ao parto pélvico por via vaginal. Todo profissional que assiste parto pélvico vaginal deve estar capacitado para a resolução adequada desses eventos. No parto pélvico vaginal em litotomia, as principais manobras para o auxílio ao desprendimento da pelve fetal são a tração inferior bidigital na prega inguinal e a manobra de Pinard; para o desprendimento do tronco fetal, as de Rojas, Deventer-Miler e Pajot; e para o desprendimento da cabeça derradeira, as de Mauriceau, Bracht, Champetier de Ribes e Praga e o parto vaginal operatório com o fórcipe de Piper. As posições não litotômicas no parto pélvico vaginal se associam à redução dos períodos de dilatação e expulsão, da taxa de cesariana, da necessidade de manobras para extração fetal e da taxa de lesões neonatais. No parto pélvico vaginal assistido na posição de quatro apoios, os aspectos a serem observados durante o desprendimento do corpo fetal incluem o tônus dos membros inferiores fetais, a rotação correta do tronco fetal (abdome fetal voltado para o dorso materno), o ingurgitamento vascular do cordão umbilical, a presença dos cotovelos e das pregas do tórax fetal e a dilatação anal materna. No parto pélvico vaginal assistido na posição de quatro apoios, mais da metade dos fetos se desprendem sem a necessidade de nenhuma manobra. Habitualmente, apenas duas manobras podem ser necessárias: uma para auxílio à saída dos ombros ("rotação 180°-90°") e outra para desprendimento da cabeça fetal ("Frank nudge").

Primary adenocarcinoma at colostomy site: report of a clinical case

Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer in the United States and it is found in 17% of patients thought to have complicated diverticular disease. However, primary adenocarcinoma rarely occur in the colostomy site and the risk of developing malignancy is similar to that of any other colonic segment. Polyps found in CRC screenings can be divided into the following types: hyperplastic polyps, polyps with no malignant potential, adenomatous polyps, polyps with malignant potential, and malignancies. Local complications of the colostomy can appear in the immediate, early, or late postoperative period, with an incidence ranging from 15 to 30%; neoplasia is even less common. (AU)

Syndrome of ventricular septal defect and aortic regurgitation - A 22-year review of its management

Abstract Introduction: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge. Methods: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR). Results: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse. Conclusion: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.

Manejo quirúrgico de prolapso uretral en pediatría: Reporte de caso / Surgical management of urethral prolapse in pediatrics: A case report

Introducción. El prolapso uretral es una entidad poco común, con una incidencia estimada de 1 en 3000 mujeres. Se presenta cuando la mucosa uretral sobresale espontáneamente más allá del meato uretral. Es una patología poco diagnosticada dada su baja frecuencia y de allí la importancia de conocer sobre su presentación, diagnóstico y tratamiento. El objetivo de este artículo fue presentar el caso de una paciente de 10 años con diagnóstico de prolapso uretral y su manejo quirúrgico. Caso clínico. Paciente femenina de 10 años, que consultó por cuadro clínico de 1 año de evolución consistente en dolor en región urogenital, que se irradiaba a hipogastrio, asociado a pujo y disuria, a quien se le diagnosticó prolapso uretral y se realizó corrección quirúrgica de mucosa uretral prolapsada mediante técnica de Kelly-Burnham modificada. Conclusión. El prolapso uretral es una entidad que con frecuencia es diagnosticada erróneamente pues su diagnóstico es eminentemente clínico. Si bien se ha descrito el tratamiento médico en primera instancia, éste tiene una alta tasa de recurrencia, por lo que en estos casos se prefiere la resección quirúrgica del tejido prolapsado.

Introduction. Urethral prolapse is a rare entity, with an estimated incidence of 1 in 3,000 women. It occurs when the urethral mucosa spontaneously protrudes beyond the urethral meatus. It is a poorly diagnosed pathology given its low frequency and hence the importance of knowing about its presentation, diagnosis and treatment. The objective of this article was to present the case of a 10-year-old patient with a diagnosis of urethral prolapse and its surgical management. Clinical case. A 10-year-old female patient, who consulted for a 1-year clinical picture consisting of pain in the urogenital region, radiating to the hypogastrium, associated with pushing and dysuria, who was diagnosed with urethral prolapse and a surgical correction of the urethral mucosa was performed prolapsed by modified Kelly-Burnham technique. Conclusion. Urethral prolapse is an entity that is frequently misdiagnosed because its diagnosis is eminently clinical. Although medical treatment has been described in the first instance, it has a high recurrence rate, so surgical resection of the prolapsed tissue is preferred in these cases.

Simple nucleus pulposus removal for the treatment of prolapsed and displaced lumbar disc herniation / 中国骨伤

OBJECTIVE@#To explore the clinical effect of the simple nucleus pulposus removal and small incision interlaminar window in the treatment of prolapsed and displaced lumbar disc herniation.@*METHODS@#From February 2016 to February 2018, 35 patients with single-segment prolapse and displaced lumbar disc herniation were treated by the simple nucleus pulposus removal and small incision interlaminar window under general anesthesia. Among them, there were 21 males and 14 females;aged (42±17) years;27 cases of L@*RESULTS@#All the operations were successful and the operation time was 30 to 60 min with an average of 40 min, the intraoperative blood loss was 10 to 30 ml with an average of 20 ml. All the patients were followed up for 1 to 3 years with an average of 1.2 years. Thirty-five patients with low back pain and lower limb symptoms were significantly relieved or disappeared. According to modified Macnab standard, 29 cases obtained excellent results, 5 good, and 1 fair.@*CONCLUSION@#Applying the concept of minimally invasive operation, small incision interlaminar window and simple nucleus pulposus removal for the treatment of prolapsed and displaced lumbar disc herniation has the advantages of short operation time, definite curative effect, and less trauma. And it is a safe and effective surgical method under the premise of strict control of the indications.

Prolapso de cúpula vaginal, prevalencia en mujeres en climaterio, en el Quindío, Colombia, 2007-2017 / Vaginal Vault Prolapse, Prevalence in Women in Climacteric, in Quindío, Colombia, 2007-2017

Objetivo establecer la prevalencia de prolapso de cúpula vaginal en mujeres del Quindío en climaterio, así como los factores asociados a su aparición. Métodos Se realizó un estudio de corte transversal. Se evaluaron retrospectivamente las historias clínicas de 3,576 pacientes ambulatorias, en una clínica de alta complejidad de la ciudad de Armenia (Quindío), Colombia; entre enero de 2007 y junio de 2017. Se determinó la prevalencia de prolapso de cúpula vaginal y se analizaron los datos socio-demográficos, clínicos y quirúrgicos. Resultados La edad media en las mujeres fue de 59,7 ± 14,7 años, con predominancia de las hispánicas (58,5%). La prevalencia de prolapso de cúpula vaginal fue del 14,17%. En el subgrupo de mujeres histerectomizadas, la prevalencia fue del 21,64% en las realizadas por prolapso y del 6,34% en las hechas vía abdominal. En el análisis multivariado, los factores asociados a prolapso de cúpula vaginal fueron: 65 o más años (OR: 4,76; 1,57­20,82), IMC[3] 25 (OR: 8,42; 2,68­31,04), multíparas (OR: 9,03; 2,75­32.27), antecedente de cirugía vaginal (OR: 7.04; 1.96­28.49) y presencia de enfermedades pulmonares crónicas (OR: 5,31; 1,64­23,57). Conclusión la prevalencia global de prolapso de cúpula vaginal, en las mujeres del Quindío, fue del 14,17%. En Colombia existen pocos datos registrados al respecto, pero con la información presente, se manifiesta la necesidad de elaborar efectivas estrategias de prevención, detección y manejo.

Objective To establish the prevalence of vaginal dome prolapse in women of Quindío in climacteric, as well as the factors associated with its appearance. Methods A cross-sectional study was performed. The medical records of 3,576 outpatients were retrospectively evaluated in a highly complex clinic in the city of Armenia (Quindío), Colombia; between January 2007 and June 2017. The prevalence of vaginal vault prolapse was determined and socio-demographic, clinical and surgical data were analyzed. Results The mean age in women was 59.7 ± 14.7 years, with a predominance of Hispanic women (58.5%). The prevalence of vaginal vault prolapse was 14.17%. In the subgroup of hysterectomized women, the prevalence was 21.64% in those performed for prolapse and 6.34% in those performed by the abdominal route. In the multivariate analysis, the factors associated with vaginal dome prolapse were: 65 or more years (OR: 4.76; 1.57­20.82), BMI[3] 25 (OR: 8.42; 2.68­31.04), multiparous (OR: 9.03; 2.75­32.27), a history of vaginal surgery (OR: 7.04; 1.96­28.49) and presence of chronic lung diseases (OR: 5.31; 1.64­23.57). Conclusion The overall prevalence of vaginal dome prolapse, in Quindío women, was 14.17%. In Colombia there are few registered data in this regard, but with the present information, there is a need to develop effective prevention, detection and management strategies.

"PNR-Bleed" classification and Hemorrhoid Severity Score-a novel attempt at classifying the hemorrhoids / Classificação "PNR-Bleed" e escore de gravidade das hemorróidas - uma nova tentativa de classificação de hemorróidas

ABSTRACT Hemorrhoids are the most common anorectal disorders with a prevalence of 39% in general population. Hemorrhoids are generally classified on the basis of their location and degree of prolapse. Goligher's classification does not describe the number of hemorrhoidal columns involved and does not give much consideration to the amount of blood loss. To describe the hemorrhoidal disease more vividly, we devised the "PNR-Bleed" (or PNR-Booking) classification system. We tried to classify the hemorrhoids based on the four main characteristics of the hemorrhoidal disease i.e. the degree of hemorrhoidal Prolapse (P), Number (N) of the primary hemorrhoidal columns involved, Relation (R) of the hemorrhoidal tissue to dentate line and the amount of Bleeding (B) from it. All the four components in this classification system are graded into five grades ranging from 1 to 5. The peculiarity of this new classification system is that it allows more detailed documentation of the hemorrhoids in a particular patient and conveys more explicit meaning and information about the hemorrhoids for future references. Based on this 'PNR-Bleed' classification, we are introducing another concept of scoring the severity of hemorrhoids and referred it as the Hemorrhoid Severity Score (HSS). Hemorrhoid Severity Score (HSS) is the total score obtained by the sum of the numerical grades of all four characteristics of hemorrhoids in "PNR-Bleed" classification. This new "PNR-Bleed" system of classifying the hemorrhoids and calculation of HSS seems to be more comprehensive, detailed, more objective and easily reproducible.

RESUMO As hemorróidas são os distúrbios anorretais mais comuns, com uma prevalência de 39% na população em geral. As hemorróidas são geralmente classificadas com base em sua localização e grau de prolapso. A classificação de Goligher não descreve o número de colunas hemorroidais envolvidas e não dá muita importância à quantidade da perda de sangue. Para descrever a doença hemorroidária de maneira mais precisa, criamos o sistema de classificação "PNR-Bleed" (ou PNR-Booking). Tentamos classificar as hemorróidas com base nas quatro principais características da doença hemorroidária, isto é, o grau de prolapso da hemorroida (P), número (N) das colunas hemorroidais primárias envolvidas, a relação (R) do tecido hemorroidário para a linha denteada e a quantidade de sangramento (B) originando-se dele. Todos os quatro componentes deste sistema de classificação são classificados em cinco graus, variando de 1 a 5. A peculiaridade desse novo sistema de classificação é que ele permite uma documentação mais detalhada das hemorróidas em um paciente em particular e transmite o significado e informações mais explícitos sobre as hemorróidas. para referências futuras. Com base nessa classificação "PNR-Bleed", estamos introduzindo outro conceito para o escore da gravidade das hemorróidas e denominado HSS, de "Hemorrhoid Severity Score". O escore de gravidade da hemorroida (HSS) é o escore total obtido pela soma dos graus numéricos de todas as quatro características das hemorróidas na classificação "PNR-Bleed". Esse novo sistema "PNR-Bleed" de classificação de hemorróidas e cálculo do HSS parece ser mais abrangente, detalhado, mais objetivo e facilmente reproduzível.

Marsupialization for the treatment of nictitating membrane cyst in a dog: case report / Marsupialização para o tratamento de cisto em membrana nictitante de cão: relato de caso

This study aims to describe the first Brazilian report of a nictitating membrane cyst's surgical treatment in a dog. A 6-month-old female French Bulldog presented at HOSVET-UNIME with a reddish mass-like structure in the medial canthus of both eyes, with a history of recurrent third eyelid gland prolapse previously treated with two surgeries performed at another clinic. Physical examination revealed a third eyelid gland prolapse in the right eye and a cyst in the left eye's third eyelid. The animal was submitted to surgical correction of the right eye's third eyelid prolapse using pocket technique and of the left eye's third eyelid using marsupialization technique for the cyst's treatment. 180 days after th1e surgical procedure no recurrence was observed. The marsupialization technique for the treatment of a third eyelid's lacrimal cyst in a dog allowed the maintenance of its gland and prevented the formation of a new cystic cavity.(AU)

O objetivo do presente trabalho é descrever o primeiro relato no Brasil de tratamento cirúrgico de um cisto da membrana nictitante em um cão. Um Buldogue Francês, fêmea, seis meses, foi atendido no Hosvet-Unime, com queixa de aumento de volume avermelhado no canto medial de ambos os olhos, com histórico de recidiva de prolapso de glândula da terceira pálpebra, onde haviam sido realizadas duas cirurgias anteriormente em outro local. Ao exame físico, foi observado prolapso de glândula da terceira pálpebra no olho direito e a presença de um cisto na terceira pálpebra do olho esquerdo. O animal foi submetido ao procedimento cirúrgico de sepultamento de glândula da terceira pálpebra no olho direito e uma marsupialização na terceira pálpebra do olho esquerdo para o tratamento do cisto. Cento e oitenta dias após o procedimento cirúrgico, não foi observada recidiva. A técnica de marsupialização para tratamento de cisto lacrimal na terceira pálpebra em um cão possibilitou a manutenção da sua glândula e impediu a formação de nova cavidade cística.(AU)

Detección de nudos críticos para la disminución del tiempo de espera en atención de prolapso de órganos pélvicos en hospital público chileno / Detecting critical knots to decrease the waiting time when caring the pelvic organ prolapse in a chilean public hospital

Resumen Introducción: El problema que se presenta en la atención de salud en los hospitales públicos es la alta cantidad de pacientes, generando un sostenido crecimiento en las listas de espera y provocando un aumento del tiempo de espera, generando un impacto negativo en los usuarios. Objetivo: Mejorar el proceso clínico de atención del prolapso de órganos pélvicos de un hospital público chileno. Metodología: Se identifican nudos críticos mediante diagramas de flujo, realizando un diagnóstico del proceso desde el ingreso del paciente hasta su alta del hospital. Resultados: Se identifican cada uno de los puntos críticos y se proponen soluciones para agilizar el proceso y con ello mejorar la atención a las usuarias, lo que en definitiva llevó a una disminución del tiempo de espera y, lo más relevante, a una disminución en la cantidad de personas en la lista de espera.

Abstract Introduction: The high number of patients is a common issue in public hospitals that causes a negative impact on the users due to the increment in the waiting lists and in the waiting time to be treated. Objective: To improve the clinical process for caring pelvic organ prolapse in a chilean public hospital. Methodology: The methodology was focused on identifying critical knots using flowcharts and diagnosing the patient's process from their admission until their discharge from the hospital. Results: Some solutions were proposed for each critical point identified so as to accelerate the process, thus improving users' health caring. As a result, the high number of people in the waiting lists and the waiting time decreased substantially.

Colpocleisis: evolution and complications in Quindío women, Colombia, 2009-2019 / Colpocleisis: evolution and complications in Quindío women, Colombia, 2009-2019

Objetivo. Evaluar y describir los resultados posoperatorios de la colpocleisis en una población de mujeres del Quindío. Materiales y métodos. Estudio de corte transversal. En una población de mujeres mayores de 69 años, con prolapso genital ≥ al grado III, sexualmente inactivas y sin interés por preservar la función sexual coital; se les realizó la colpocleisis de LeFort (entre 2009 y 2019). La investigación se efectuó en una institución prestadora de servicios de salud privada, de nivel III, en la ciudad de Armenia. Las mujeres fueron evaluadas antes del procedimiento, luego en las primeras 2 semanas, a los 6 meses, a los 12 meses y después cada año. Resultados. Se operaron 102 mujeres, 69 (67,64 %) por prolapso grado IV y 33 (32,35 %) grado III. La edad media fue de 75,39 ± 8,46 años, con un IMC de 27,48 ± 7,59. El tiempo quirúrgico promedio fue 45,93 ± 18,63 minutos. La mediana de la hemorragia transquirúrgica fue de 75 mL. El éxito quirúrgico alcanzado fue del 98,03 %. Conclusiones. La colpocleisis de LeFort, como tratamiento del prolapso genital ≥ al grado III, ofrece una tasa de mejoría cercana al 98,03 %, con mínimas complicaciones

Objective. To evaluate and describe the postoperative results of colpocleisis in a population of women from Quindío. Materials and methods. Cross-sectional study. In a women population older than 69 years, with genital prolapse ≥grade III, sexually inactive and without interest in preserving coital sexual function; They underwent LeFort colpocleisis (between 2009 and 2019). The research was conducted at a private level III in a health care institution in the city of Armenia. The women were evaluated before the procedure, then in the first 2 weeks, at 6 months, at 12 months, and then every year. Results. 102 women underwent surgery, 69 (67.64%) for grade IV prolapse and 33 (32.35%) grade III. The average age was 75.39 ± 8.46 years (range 69 - 96), with a BMI of 27.48 ± 7.59 (range 18.36 - 42.39). The average surgical time was 45.93 ± 18.63 minutes. The median trans-surgical bleeding was 75 mL. The surgical success achieved was 98.03%. Conclusions. LeFort colpocleisis, as a treatment for genital prolapse ≥ grade III, offers an improvement rate of about 98.03%, with minimal complications.

Prolapso uretral en una niña con sangrado urogenital / Urethral prolapse in a girl with urogenital bleeding

El prolapso uretral es una enfermedad poco frecuente que afecta a la uretra distal. Ocurre, con mayor frecuencia, en niñas negras prepúberes y en mujeres posmenopáusicas. El motivo de consulta suele ser sangrado genital y/o disuria. El tratamiento incluye desde terapia conservadora hasta operaciones quirúrgicas.Se presenta el caso de una niña blanca de 11 años que acudió a Urgencias por flujo vaginal desde hacía 6 días y sangrado genital desde hacía 3 días, que se acompañaba de dolor punzante en la región genital, con disuria ocasional. Se observó una eversión circular de la mucosa uretral con un área granulomatosa y necrótica, por lo que se intervino quirúrgicamente y se realizó una resección del prolapso, con resolución de la clínica

Urethral prolapse is an uncommon condition that involves the distal urethra. It occurs most often in prepuberal black girls and in postmenopausal women. The reason for consultation is usually genital bleeding and/or dysuria. The treatment includes from conservative therapy to surgical interventions.We present the case of an 11-year-old white girl who came to the Emergency Room due to vaginal discharge for 6 days and genital bleeding for 3 days that was accompanied by stabbing pain in genital region, with occasional dysuria. A circular eversion of the urethral mucosa was observed, so the patient was surgically intervened, performing a prolapse resection with clinical resolution

Local treatment of colostomy prolapse with the MESH STRIP technique: A novel and highly efficient day hospital technique

OBJECTIVE: Stoma prolapse is an intussusception of the bowel through a mature stoma. It can be caused by increased intra-abdominal pressure, excessively mobile bowel mesentery and/or a large opening in the abdominal wall at the time of stoma formation. It occurs predominantly in loop stomas, and correction methods include conservative modalities, such as local reduction to the prolapsed bowel, or surgical treatment. The purpose of this study was to describe our experience with the treatment of colostomy prolapse using a novel mesh strip technique. METHODS: Between February 2009 and March 2018, ten consecutive male patients underwent correction of colostomy prolapse under local anesthesia by peristomal placement of a polypropylene mesh strip. Operation time, short- and long-term complications, and recurrence rates were recorded and analyzed. RESULTS: No postoperative complications, morbidity or mortality were observed. The median length of the prolapse ranged from 6-20 cm, and the median operative time was 30 minutes. The median duration of follow-up was 25 months (range, 12-89 months). No relapse, mesh strip extrusion, local infection or granuloma formation were found. CONCLUSION: A simple, fast, and low-cost operation under local anesthesia using a mesh strip is a valuable option to treat colostomy prolapse.

Insuficiencia cervical y prolapso de bolsa amniótica "en reloj de arena"en gestante pretérmino / Cervical Insufficiency and Prolapse of an "Hourglass" Amniotic Sac in Preterm Pregnant Women

RESUMEN Introducción: La insuficiencia cervical se concibe hoy día como un proceso biológico continuo con grados progresivos de insuficiencia. La expresión más extrema de la insuficiencia cervical se conoce como "bolsa en reloj de arena". La mayoría de los autores están de acuerdo en recomendar el reposo en cama y realizar cerclaje cervical de emergencia. Objetivo: Presentar el caso de una gestante en la que se logró la reversión del prolapso de las membranas amnióticas en "reloj de arena" con buenos resultados perinatales. Presentación de caso: Paciente de 31 años con antecedentes de parto anterior a las 36,5 semanas, que en los momentos actuales cursa una gestación de 20,6 semanas. Acude a la consulta por dolor en hipogastrio y al examen físico se comprueba que la bolsa amniótica protruye por el orificio cervical externo y presenta una dilatación cervical de 2 cm. Se aplica tratamiento medicamentoso y se reduce el prolapso de la bolsa. Conclusiones: Con el tratamiento conservador se logró una buena evolución de la gestación, con parto eutócico y buenos resultados perinatales(AU)

ABSTRACT Introduction: Cervical insufficiency is conceived today as a continuous biological process with progressive degrees of insufficiency. The most extreme expression of cervical insufficiency is known as "hourglass bag". Most authors agree to recommend bed rest and perform emergency cervical cerclage. Objective: To report the case of a pregnant woman in whom the prolapse reversal of the amniotic membranes in hourglass was achieved with good perinatal results. Case report: A 31-year-old patient who is currently pregnant at 20.6 weeks and has history of childbirth prior to 36.5 weeks. She comes to the consultation complaining of pain in hypogastrium. The physical examination shows that the amniotic sac protrudes through the external cervical orifice and there is 2cm cervical dilation. Drug treatment is applied and the prolapse of the sac is reduced. Conclusions: The conservative treatment achieved good evolution of the gestation, with eutócico childbirth and good perinatal results(AU)

Common operation, uncommon complication. Bleeding from superior haemorrhoidal artery after minimally invasive procedure for hemorrhoids - a case report / Operação comum, complicação incomum. Sangramento de artéria hemorroidária superior após PMIH - um relato de caso

ABSTRACT Minimally invasive procedure for hemorrhoids is one of the commonest new wave operations done for prolapsed hemorrhoids. The diameter of the stapled tissue is critical in this operation, and an increase in the same could include more tissue in the anvil, with disastrous results. This is a case report of a post minimally invasive procedure for hemorrhoids bleed, which was refractory to two local oversewing attempts. When the bleeding was massive, an angiogram was obtained. This revealed a pseudo aneurysm of the left superior haemorrhoidal artery, which was embolized, stopping the bleed. The stapler dimensions were studied and the possible cause of the event was arrived at. The specific stapler used had a diameter of 2 mm more than the regular Medtronic and Ethicon staplers, possibly including more of the rectal wall, and the superior haemorrhoidal artery as well. This case report documents a rare and potentially fatal complication of a simple procedure.

RESUMO O procedimento minimamente invasivo para as hemorroidas (PMIH) é uma das novas operações mais comuns para ao tratamento de hemorroidas prolapsadas. O diâmetro do tecido grampeado é crítico nessa operação; um aumento nesse diâmetro poderia colocar mais tecido na bigorna do grampeador, com resultados desastrosos. Este relato de caso descreve o desfecho de uma hemorragia após PMIH, refratária a duas tentativas locais de sobressutura. Um angiograma foi realizado quando a hemorragia foi considerada intensa. O exame revelou um pseudoaneurisma da artéria hemorroidária superior esquerda, que foi embolizada, interrompendo o sangramento. As dimensões do grampeador foram estudadas e descobriu-se a possível causa do evento. O grampeador específico usado tinha um diâmetro 2 mm maior do que os grampeadores regulares da Medtronic e da Ethicon e possivelmente captou uma área maior da parede retal e a artéria hemorroidária superior. Este relato de caso documenta uma complicação rara e potencialmente fatal de um procedimento simples.

Response to: Zygapophyseal Joint Orientation and Facet Tropism and Their Association with Lumbar Disc Prolapse

No abstract available.

Zygapophyseal Joint Orientation and Facet Tropism and Their Association with Lumbar Disc Prolapse

No abstract available.

Factors Affecting Early and 1-Year Motor Recovery Following Lumbar Microdiscectomy in Patients with Lumbar Disc Herniation: A Prospective Cohort Review

STUDY DESIGN: Prospective cohort study. PURPOSE: The study was aimed at evaluating clinicoradiological factors affecting recovery of neurological deficits in cases of lumbar disc herniation (LDH) treated by lumbar microdiscectomy. OVERVIEW OF LITERATURE: The majority of the available literature on neurological recovery following neurodeficit is limited to retrospective series. The literature is currently limited regarding variables that can help predict the recovery of neurodeficits following LDH. METHODS: A prospective analysis was performed on 70 consecutive patients who underwent lumbar microdiscectomy (L1–2 to L5–S1) owing to neurological deficits due to LDH. Patients with motor power ≤3/5 in L2–S1 myotomes were considered for analysis. Follow-up was performed at 2, 6, and 12 months to note recovery of motor deficits. Clinicoradiological parameters were compared between the recovered and nonrecovered groups. RESULTS: A total of 65 patients were available at the final follow-up: 41 (63%) had completely recovered by 2 months; four showed delayed recovery at the 6-month follow-up; and 20 (30.7%) showed no recovery at 1 year. Clinicoradiological factors, including diabetes, complete initial deficit, areflexia, multilevel disc prolapse, longer duration since initial symptoms, and ≥2 previous symptomatic episodes were associated with a significant risk of poorer recovery (p 0.05 for all). Diabetes mellitus (p=0.033) and complete initial motor deficit (p=0.028) were significantly associated with delayed recovery in the multivariate analysis. CONCLUSIONS: The overall neurological recovery rate in our study was 69%. Diabetes mellitus (p=0.033) and complete initial motor deficit were associated with delayed motor recovery.

Utility of Cardiac CT for Preoperative Evaluation of Mitral Regurgitation: Morphological Evaluation of Mitral Valve and Prediction of Valve Replacement

OBJECTIVE: We aimed to investigate the diagnostic accuracy of cardiac computed tomography (CT) for the detection of mitral valve (MV) prolapse in mitral regurgitation (MR) with surgical findings as the standard reference, and to assess the predictability of MV replacement based on morphologic CT findings. MATERIALS AND METHODS: A total of 156 patients who had undergone preoperative cardiac CT and subsequently received MV surgery due to severe MR were retrospectively enrolled. Non-repairable MV was defined when at least one of the following conditions was met: 1) anterior leaflet prolapse, 2) bi-leaflet prolapse, or 3) valve morphology (leaflet thickening, calcification, or mitral annular calcification [MAC]). Diagnostic performance of CT for the detection of the prolapsed segment was assessed with surgical findings as the standard reference. Logistic regression analysis was performed to evaluate the value of CT findings to predict actual valve replacement. RESULTS: During surgery, MV prolapse was identified in 72.1%. The sensitivity, specificity, and diagnostic accuracy for the detection of MV prolapse were 99.1%, 81.4%, and 94.2%, respectively, per patient. One-hundred eighteen patients (75.6%) underwent MV repair and the remaining 38 patients received MV replacement. Bi-leaflet prolapse and valve morphology were independent predictors of valve replacement after adjusting for clinical variables (adjusted odds ratio, [OR] 8.63 for bi-leaflet prolapse; OR, 4.14 for leaflet thickening; and OR, 5.37 for leaflet calcium score > 5.6; p < 0.05). CONCLUSION: Cardiac CT can have high diagnostic performance for detecting the prolapsed segment of the MV and predictability of valve replacement before surgery. Bi-leaflet prolapse and valve morphology, such as leaflet thickening, or calcification or MAC, are the most important predictors of valve replacement.

Surgical Treatment of Rectal Prolapse: A 10-Year Experience at a Single Institution

PURPOSE: Despite the plethora of surgical options, there is no consensus regarding the best treatment for rectal prolapse. This study is aimed at evaluating our experience with its treatment and outcomes.METHODS: We retrospectively reviewed rectal prolapse patients' characteristics, clinical presentation, surgical procedure, average length of hospital stay, morbidity, mortality, and recurrence over a 10 year period at our institution.RESULTS: A total of 46 patients underwent rectal prolapse repair at our institution over a 10 year period. Of the 39 patients with primary rectal prolapse, 18 patients had an abdominal procedure, while 21 patients underwent a perineal approach. Operative duration was significantly longer in abdominal procedures, of which 16 cases were performed laparoscopically. Length of hospital stay and recurrence were not statistically significant between the 2 groups. In patients with recurrent rectal prolapse, more than 80% of the initial surgeries were done using the perineal approach. An abdominal approach was utilized in the management of 75% of recurrences.CONCLUSION: An abdominal repair may be preferable in the treatment of recurrent rectal prolapse. Minimally invasive techniques may be feasible and can provide a safe alternative to perineal procedures in elderly patients.