Retroperitoneal abscess after transanal minimally invasive surgery: case report and review of literature / Abscesso retroperitoneal após cirurgia de ressecção transanal minimamente invasiva: relato de caso clínico e revisão a literatura médica

ABSTRACT Abscesses are a rare complication of transanal minimally invasive surgery and transanal endoscopic micro surgery. Reported cases have been in the rectal and pre-sacral areas and have been managed with either antibiotics alone or in conjunction with laparotomy and diverting colostomy. We report a case of a large retroperitoneal abscess following a Transanal minimally invasive surgery full thickness rectal polyp excision. The patient was successfully managed conservatively with antibiotics and a percutaneous drain. Retroperitoneal infection should be included in a differential diagnosis following a Transanal minimally invasive surgery procedure as the presentation can be insidious and timely intervention is needed to prevent further morbidity.

RESUMO Os abscessos são uma complicação rara da cirurgia de ressecção transanal minimamente invasiva (TAMIS) e da micro cirurgia endoscópica transanal (TEMS). Os casos notificados foram nas áreas rectal e pré-sacral e foram administrados com antibióticos isoladamente ou em conjunto com laparotomia e desvio de colostomia. Relatamos um caso de grande abscesso retroperitoneal após uma excisão de pólipo retal de espessura total TAMIS. O paciente foi tratado com sucesso com a administração de antibióticos e drenagem percutânea. Para prevenir mais morbidade é necessária incluir a infecção retroperitoneal no diagnostico diferencial após um procedimento TAMIS onde a apresentação pode ser insidiosa e a intervenção atempada.

Trombosis venosa profunda y hemorragia retroperitoneal espontánea, una combinación fatal / Deep venous thrombosis and spontaneous retroperitoneal haemorrhage, a fatal combination

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Should We Change the Initial Treatment of Renal or Retroperitoneal Abscess in High Risk Patients?

INTRODUCTION: This study examined the risk factors for initial treatment failure in renal or retroperitoneal abscess as a multicenter study. MATERIALS AND METHODS: This retrospective analysis investigated consecutive patients with renal or retroperitoneal abscess who were hospitalized in Japan. The outcomes of these patients were classified into "cured" and "failure or recurrence." The potential clinical risk factors examined were abscess size, diabetes mellitus, major organ failure, laboratory data, fever, drainage, and causative organisms, for instance. RESULTS: Of the 74 patients, 40 (54.1%) were diagnosed with renal abscess and 34 (45.9%) with retroperitoneal abscess, 51 (68.9%) were cured by initial treatments, and 23 (31.1%) underwent failure or relapse; 33 (44.6%) were men and 41 (55.4%) were women. In detail, 36 patients were cured by conservative therapy only. Our multivariate analysis data showed that renal failure was the only significant factor for initial treatment failure (p = 0.0281). CONCLUSIONS: Our multivariate analysis showed that renal failure was a significant risk factor for initial treatment failure or recurrence.

Síndrome de Wünderlich: una causa infrecuente de abdomen agudo / No disponible

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Hemorragia retroperitoneal espontánea de origen renal (síndrome de Wunderlich): análisis de 8 casos / Spontaneous retroperitoneal haemorrhage of renal origin (Wunderlich syndrome): Analysis of 8 cases

OBJETIVO: Analizar las características, etiología y tratamiento en una serie de pacientes con hemorragia retroperitoneal espontánea de causa renal. MÉTODOS: Revisamos retrospectivamente los pacientes diagnosticados de hemorragia retroperitoneal espontanea entre 2006 y 2011. Todos los pacientes consultaron por dolor lumbar y el diagnóstico se realizó mediante Tomografía computada (TC) y/ o Resonancia magnética (RM). Todos los pacientes fueron tratados quirúrgicamente. RESULTADOS: La serie está compuesta por 8 pacientes. Seis casos presentaron masa renal y hematoma asociado y en 2 solo se apreció un hematoma perirenal. Seis pacientes fueron tratados mediante nefrectomía total, uno mediante nefrectomía parcial y otro solo con drenaje del hematoma. El estudio anátomo-patológico demostró 4 casos de Angiomiolipoma renal (uno asociado a múltiples carcinomas renales pequeños), 2 casos de Carcinoma renal y 1 caso de infarto renal hemorrágico. CONCLUSIÓN: Las masas renales constituyen la principal causa de síndrome de Wünderlich y la TC es la técnica diagnostica de elección. El tratamiento quirúrgico es de elección en pacientes con masa renal diagnosticada y en casos de compromiso hemodinámico (AU)

OBJECTIVES: To analyze the characteristics, etiology and treatment of a series of patients with spontaneous retroperitoneal hemorrhage from renal causes. METHODS: We retrospectively reviewed patients diagnosed of spontaneous retroperitoneal hemorrhage between 2006 and 2011. All patients consulted for back pain and the diagnosis was made by computed tomography (CT) and / or magnetic resonance (MR). All patients were treated surgically. RESULTS: The series includes 8 patients. Six cases had renal mass and associated hematoma and 2 presented only perirenal hematoma. Six patients underwent total nephrectomy, one underwent partial nephrectomy, and one just drainage of the hematoma. The pathological study showed 4 cases of renal angiomyolipoma (one associated with multiple small renal carcinomas), 2 cases of renal carcinoma and 1 case of hemorrhagic renal infarction. CONCLUSION: Renal masses are the main cause of Wunderlich syndrome and CT is the diagnostic procedure of choice. Surgical treatment is preferred in patients with renal mass diagnosed and cases of hemodynamic compromise (AU)

Enfermedad de Erdheim-Chester: aportación de un caso con afectación retroperitoneal tratado con interferón alfa-2a / Erdheim-Chester disease: Report of a case with retroperitoneal involvement treated with interferon alpha-2a

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Feasibility and outcomes of laparoscopic renal intervention after prior open ipsilateral retroperitoneal surgery.

BACKGROUND AND PURPOSE: Treating patients with renal-cell carcinoma (RCC) after previous retroperitoneal surgery (renal or adrenal) is technically challenging. We present our initial experience with laparoscopic renal interventions (LRI) after previous open retroperitoneal surgery in patients needing ipsilateral renal intervention. We report on feasibility, functional and oncologic outcomes of LRI after previous open retroperitoneal surgery. PATIENTS AND METHODS: We reviewed records of patients undergoing attempted laparoscopic or robot-assisted renal intervention after at least one previous open ipsilateral retroperitoneal surgery. We identified 34 patients who underwent 39 staged attempted LRI after 48 previous open ipsilateral renal or adrenal surgeries. The LRI included 20 minimally invasive partial nephrectomies (MIPN), 11 laparoscopic radiofrequency ablations (LRFA), and 8 laparoscopic nephrectomies (LTN). Demographic, perioperative, renal functional, and oncologic outcome data were collected. Statistical analyses were performed to identify risks for conversion to open surgery. RESULTS: No attempted nephron-sparing procedure resulted in kidney loss. Overall conversion rate of the cohort was 28% and was highest in the MIPN group (40%). On univariate analysis, only multiple tumors that were treated significantly increased chances of open conversion (P<0.01). Subset analysis demonstrated similar rates of blood loss, operative times, and conversion rates in patients undergoing partial nephrectomy having previous open partial nephrectomy compared with previous open adrenal surgery only. There was no significant difference in preservation of renal function between MIPN and LRFA, with more than 85% of preoperative renal function preserved. Mean follow-up of 11.9 months (range 1-97.5 mos) metastasis-free survival and overall survival was 94.1% and 97%, respectively. CONCLUSIONS: LRI after previous open ipsilateral retroperitoneal surgery is feasible. Repeated partial nephrectomy has the highest conversion risks among the laparoscopic renal interventions and appears to be independent of previous renal or adrenal procedure. Attempting repeated LRI for multiple tumors is a significant risk factor for open conversion. Renal functional and oncologic outcomes are encouraging at early follow-up.

[The changes of intraabdominal pressure in patients with retroperitoneal bleeding].

The linear dependence of the intraabdominal pressure and the volume of retroperitoneal bleeding was revealed in 34 patients with the aortic aneurism rupture. In patients with the blunt abdominal trauma, treated conservatively and laparotomized (each group consisted of 26 patients), the intraabdominal pressure is higher in the operated group during the first day after the operation. The main factors of the intraabdominal hypertension seem to be shock and massive infusion and transfusion therapy.

The effect of the retroperitoneal transpsoas minimally invasive lateral interbody fusion on segmental and regional lumbar lordosis.

BACKGROUND: The minimally invasive lateral interbody fusion (MIS LIF) in the lumbar spine can correct coronal Cobb angles, but the effect on sagittal plane correction is unclear. METHODS: A retrospective review of thirty-five patients with lumbar degenerative disease who underwent MIS LIF without supplemental posterior instrumentation was undertaken to study the radiographic effect on the restoration of segmental and regional lumbar lordosis using the Cobb angles on pre- and postoperative radiographs. Mean disc height changes were also measured. RESULTS: The mean follow-up period was 13.3 months. Fifty total levels were fused with a mean of 1.42 levels fused per patient. Mean segmental Cobb angle increased from 11.10° to 13.61° (P < 0.001) or 22.6%. L2-3 had the greatest proportional increase in segmental lordosis. Mean regional Cobb angle increased from 52.47° to 53.45° (P = 0.392). Mean disc height increased from 6.50 mm to 10.04 mm (P < 0.001) or 54.5%. CONCLUSIONS: The MIS LIF improves segmental lordosis and disc height in the lumbar spine but not regional lumbar lordosis. Anterior longitudinal ligament sectioning and/or the addition of a more lordotic implant may be necessary in cases where significant increases in regional lumbar lordosis are desired.

Effects of pelvic volume changes on retroperitoneal and intra-abdominal pressure in the injured pelvic ring: a cadaveric model.

BACKGROUND: Pelvic ring injuries can be associated with severe blood loss and hemodynamic instability. The increase in pelvic volume in disrupted pelvic ring injuries is thought to cause accumulation of large volumes of blood in the retroperitoneal cavity. Extra abdominal compression for reduction of the pelvic ring may affect intrapelvic pressure. We examined the effects of pelvic volume changes on retroperitoneal pressures (RPP) and intra-abdominal pressures (IAPs) in the intact and unstable pelvic ring. METHODS: In a cadaver study, unembalmed human torsos were used. Infusion lines were placed adjacent to the sacroiliac joint in the retroperitoneum and in the abdominal cavity. IAP and RPP measurements were performed with sequential infusion of crystalloid solution in 1,000 mL increments. Measurements were performed in the intact pelvic ring and after induction of unilateral and bilateral instability by disruption of the pubic symphysis, the sacroiliac joints, the sacrotuberous ligaments, and sacrospinous ligaments. RESULTS: After infusion of 4,000 mL of saline, we observed a pressure increase in the retroperitoneal cavity (RPP) of 19.64 mm Hg ± 6.43 mm Hg in the intact pelvis, 5.22 mm Hg ± 1.74 mm Hg in unilateral instability, and 2.78 mm Hg ± 0.57 mm Hg in bilateral instability. The RPP response in the case of instability decreased significantly (p = 0.019). The IAP showed a change of 4.63 mm Hg ± 2.64 mm Hg in the intact pelvis, 3.88 mm Hg ± 1.84 mm Hg in unilateral instability, and 2.30 mm Hg ± 0.36 mm Hg in bilateral instability. Further infusion revealed a close association between RAPs and IAPs. CONCLUSIONS: In the intact pelvis, RPP rises rapidly with increasing volume. The results seem to support the idea that disrupted pelvic ring fractures may lead to a significant volume uptake that is reversed during reduction.

Spontaneous peritoneal and retroperitoneal hemorrhage, rare serious complication following carotid angioplasty with stent.

Carotid artery stenting (CAS) has been accepted as a relatively safe and effective treatment modality for patients with symptomatic severe carotid stenosis. We report a rare case of 75-year-old male with spontaneous peritoneal and perirenal hemorrhage following carotid angioplasty with stent. Because this intraabdominal hemorrhage can cause delayed diagnosis and treatment due to vague symptoms and the lack of suspicion of the hemorrhage, and can induce fatal condition, physicians should be aware that the abdominal hemorrhage could occur as a rare but serious complication after CAS without puncture site problems or iatrogenic injury.

Rotura crónica de aneurisma de aorta abdominal y fístula arteriovenosa intrarrenal como complicación de la cirugía aórtica / Chronic rupture of an abdominal aortic aneurysm and an intrarenal arteriovenous fi stula as a complication of aortic surgery

Introducción. La rotura crónica es una complicación muy poco frecuente del aneurisma de aorta abdominal cursa con una clínica insidiosa y sin repercusión hemodinámica lo que permite planificar el tratamiento quirúrgico. Caso clínico. Varón de 73 años con lumbalgia crónica es diagnosticado de forma casual de aneurisma de aorta abdominal y hematoma retroperitoneal crónico que le había producido una osteólisis intensa de los cuerpos vertebrales L3-L5. Se programó el tratamiento quirúrgico, manifestándose en el postoperatorio una fístula intrarrenal sintomática que se resolvió con una embolización selectiva. Conclusión. La rotura contenida de aneurisma de aorta debe ser considerada como una causa rara en el diagnóstico diferencial del dolor lumbar crónico en los pacientes de edad avanzada(AU)

Introduction. Chronic rupture is a rare complication of AAA (abdominal aortic aneurysm). The clinical course is insidious and with no haemodynamic repercussions, which means it may be treated surgically. Clinical case. A 73 year-old male with chronic lumbar pain was diagnosed by chance with an AAA and a chronic retroperitoneal haematoma, which had caused severe osteolysis in the L3-L5 vertebral bodies. Surgical treatment was scheduled, with a symptomatic intrarenal fistula appearing in the post-operative period, which was resolved with selective embolisation. Conclusion. The contained aortic aneurysm rupture should be considered as a rare cause in the differential diagnosis of chronic lumbar pain in patients of advanced age(AU)

Intra-abdominal hypertension: pulmonary and cerebral complications.

Intra-abdominal hypertension causes many physiologic changes, primarily by reducing thoracic compliance and secondarily causing organ failure, which is the body's normal response to trauma or acute inflammatory response. Compartment syndrome as a cause of abdominal hypertension has adverse effects on the circulation, threatening the function and viability of tissues. Intra-abdominal hypertension with the clinical picture of compartment syndrome is a reperfusion injury that is a cyclic event. Elevated intra-abdominal pressure due to whatever mechanism affects all intra-abdominal viscera, including the abdominal wall. Due to edema reducing thoracic compliance, producing severe encephalopathy and leading to severe ischemia with generation of significant quantities of reactive oxygen free radicals as well peroxidation products released from the intestine, liver and spleen. Elevated intracranial pressure causes encephalopathy and the risk of neuronal damage due to the sharp decrease in cerebral perfusion pressure. Elevated intracranial pressure is due to restriction of outflow from the lumbar venous plexus. The etiology of the sudden increase in capillary permeability remains unclear. Decompressive laparotomy leads to a rapid improvement in pulmonary parameters and oxygen delivery. The clinical state after decompression is an example of ischemia-reperfusion injury requiring therapy with inotropes and other agents to improve cardiac, respiratory, renal and cerebral hemodynamics with life saving effects.

Hemorragia retroperitoneal espontánea: nuestra experiencia en los últimos 10 años / Spontaneous retroperitoneal hemorrhage: our experience at last 10 years

Introducción y Objetivos: El análisis de la etiología, manifestaciones clínicas, métodos diagnósticos y tratamiento empleado en la hemorragia retroperitoneal espontánea (HRE), en nuestra serie de pacientes. Métodos: Presentamos 27 casos de HRE diagnosticados en nuestro hospital entre Enero de 1996 y Diciembre de 2005. Las técnicas de imagen empleadas fueron ecografía abdominal, TC abdomino-pélvica y resonancia magnética. Resultados: La causa más frecuente de sangrado fue la rotura de un angiomiolipoma renal en 7 pacientes. Entre las manifestaciones clínicas, el dolor lumbar o abdominal fue el síntoma predominante. La ecografía abdominal detectó el hematoma en el 81,8% de pacientes, aportando un diagnóstico etiológico en tan sólo el 40,9% de los casos. La TC abdomino-pélvica reveló la hemorragia retroperitoneal en todos casos, y además diagnosticó en el 92,6%, el origen del sangrado. El tratamiento fue cirugía de urgencia en 10 pacientes, mientras que en los 17 restantes se optó, inicialmente, por medidas terapéuticas conservadoras. Conclusiones: En nuestra experiencia, en los casos de HRE, la TC abdomino-pélvica es la prueba diagnóstica de elección y el manejo terapéutico de esta patología deberá individualizarse en función de la situación hemodinámica del paciente y la etiología del síndrome

Introduction and Objectives: Etiology, clinical features, diagnostic methods and treatment of spontaneous retroperitoneal hemorrhage were analyzed. Methods: We report 27 cases with diagnosis of spontaneous retroperitoneal hemorrhage treated in our hospital between January 1996 and December 2005. The imaging techniques were abdominal ultrasonography, abdominal CT scan and MRI. Results: The most common cause of retroperitoneal hemorrhage was renal angiomyolipoma rupture in 7 patients. Continuous flank or abdominal pain were the primary symptoms. Abdominal ultrasonography showed hematoma in 81.8% patients, but the actual etiologic diagnosis was ascertained in only 40.9% of them. Retroperitoneal hemorrhage was demonstrated by means of abdominal CT scan in all cases and bleeding origin was established in 92.6% of cases. Ten patients underwent urgent surgery while conservative treatment was attempted in the remaining 17. Conclusions: In our experience, in cases of spontaneous retroperitoneal hemorrhage, CT scan is the best imaging method to establish the diagnosis and the management of such entity although it will need to be individualized for every case because it depends on the hemodinamic situation and etiologic diagnosis

Traumatic spinal cord infarction in a child: case report and review of literature.

BACKGROUND: Traumatic spinal cord infarction was initially described in the era previous to the availability of MRI. This entity occurs in children and affects the thoracic spinal cord, usually presenting as a delayed cord injury. Patients have a high incidence of associated blunt thoracic or retroperitoneal trauma and arterial hypotension at admission. The described mechanism of injury is a traumatic occlusion of the aortic branches nourishing the spinal cord. It shares several characteristics with SCIWORA. In past years, the presence of this injury has received little importance. CASE DESCRIPTION: A 5-year-old boy suffered from high-energy blunt trauma over the thoracoabdominal area, presenting hypotension, retroperitoneal injury, and delayed complete thoracic SCI. An MRI showed spinal cord infarction located in the territory of AKA. During subsequent examinations, the boy did not show signs of neurological improvement. CONCLUSION: It is important to include TSCIf in the diagnosis of children who present delayed SCI (hours to 4-5 days), especially if the injury is located in the thoracic cord and is accompanied by blunt thoracic or abdominal trauma. Because the conventional radiographic tests are normal, TSCIf can be considered as a special type of SCIWORA.

Spontaneous healing of retroperitoneal chylous leakage following anterior lumbar spinal surgery: a case report and literature review.

Cisterna chyli is prone to injury in any retroperitoneal surgery. However, retroperitoneal chylous leakage is a rare complication after anterior spinal surgery. To the best of our knowledge, only ten cases have been reported in the English literature. We present a case of a 49-year-old man who had lumbar metastasis and associated radiculopathy. He had transient retroperitoneal chylous leakage after anterior tumor decompression, interbody bony fusion, and instrumental fixation from L2 to L4. The leakage stopped spontaneously after we temporarily clamped the drain tube. Intraperitoneal ascites accumulation developed thereafter due to nutritional loss and impaired hepatic reserves. We gathered ten reported cases of chylous leak after anterior thoracolumbar or lumbar spinal surgery, and categorized all these cases into two groups, depending on the integrity of diaphragm. Six patients received anterior spinal surgery without diaphragm splitting. Postoperative chylous leak stopped after conservative treatment. Another five cases received diaphragm splitting in the interim of anterior spinal surgery. Chylous leakage stopped spontaneously in four patients. The remaining one had a chylothorax secondary to postop chyloretroperitoneum. It was resolved only after surgical intervention. In view of these cases, all the chylous leakage could be spontaneously closed without complications, except for one who had a secondary chylothorax and required thoracic duct ligation and chemopleurodesis. We conclude that intraoperative diaphragm splitting or incision does not increase the risk of secondary chylothorax if it was closed tightly at the end of the surgery and the chest tube drainage properly done.

Cirugía conservadora de urgencia en monorrena por rotura de angiomiolipoma múltiple / Emergency conservative surgery on a unique kidney with broken multiple angiolypoma

Se presenta el caso una hemorragia retroperitoneal debida a la rotura de un angiomiolipoma (AML) en una paciente monorrena. La paciente debuta con un shock hipovolémico por lo que es necesario realizar una cirugía de urgencia, pudiendo ser en este caso conservadora. Se revisan así mismo las distintas etiologías, diagnóstico y tratamiento de la hemorragia retroperitoneal espontánea

A case of retroperitoneal hemorrhage due to the rupture of a multiple angiomyolipoma in a female with a unique kidney is described. Hipovolemic shock was the first symptom, being possible to perform on her a successful conservative surgery. Etiology, diagnostic methods and treatment of the spontaneous retroperitoneal hemorrhage are discussed