Presentación inusual de quiste dermoide en piso de boca: reporte de caso y revisión de la literatura / Unusual presentation of dermoid cyst in the mouth floor: case report and literature review

Los Quistes Derrmoides son una patología frecuente, pero su localización en la cavidad oral es excepcional; cuando se presentan en el suelo de la boca muestran una tumoración benigna de la línea media. Para el abordaje quirúrgico son factores determinantes su tamaño y las relaciones anatómicas; sin embargo la exéresis intrabucal demuestra beneficios estéticos y funcionales. Se presenta el caso de una paciente de 9 años de edad, con aumento de volumen en el piso de la boca y región submentoniana, de 2 años de evolución, crecimiento lento, progresivo y asintomática. Se realizaron estudios complementarios y bajo anestesia general nasotraqueal, se procedió a su exéresis quirúrgica mediante un abordaje intrabucal. El diagnóstico histopatológico reportó Quiste Dermoide en el suelo de la boca. La paciente no ha tenido recurrencia de la lesión transcurridos 1 año de la cirugía.

The Derrmoid Cysts are a frequent pathology, nevertheless their location in the oral cavity is exceptional, when they occur in the floor of the mouth they show a benign tumor of the midline. Their size and anatomical location are determining factors in the surgical approach; however, the intra-oral exeresis demonstrates aesthetic and functional benefits. We present the case of a 9-year-old patient, with increased volume in the floor of the mouth and submental region, of 2 years of evolution, slow growth, progressive, asymptomatic. Complementary studies were carried out and under nasotracheal general anesthesia, we proceeded to surgical exeresis through an intra-oral approach. The histopathological diagnosis reported a Dermoid Cyst in the floor of the mouth. The patient had no recurrence of the lesion 1 year after the operation. A review is made about the diagnosis and surgical approaches of the Dermoid Cysts.

Cessation of oral anticoagulants in antiphospholipid syndrome.

Objective To study the outcome of patients with antiphospholipid syndrome (APS) after oral anticoagulant treatment cessation. Methods We performed a retrospective study of patients with APS experiencing cessation of oral anticoagulant and enrolled in a French multicentre observational cohort between January 2014 and January 2016. The main outcome was the occurrence of recurrent thrombotic event after oral anticoagulation cessation. Results Forty four APS patients interrupted oral anticoagulation. The median age was 43 (27-56) years. The median duration of anticoagulation was 21 (9-118) months. Main causes of oral anticoagulant treatment cessation were switch from vitamin K antagonists to aspirin in 15 patients, prolonged disappearance of antiphospholipid antibodies in ten, bleeding complications in nine and a poor therapeutic adherence in six. Eleven (25%) patients developed a recurrent thrombotic event after oral anticoagulation cessation, including three catastrophic APS and one death due to lower limb ischemia. Antihypertensive treatment required at time of oral anticoagulants cessation seems to be an important factor associated with recurrent thrombosis after oral anticoagulant cessation (15.2% in patients with no relapse versus 45.5% in patients with recurrent thrombosis, p = 0.038). Oral anticoagulant treatment was re-started in 18 (40.9%) patients. Conclusion The risk of a new thrombotic event in APS patients who stopped their anticoagulation is high, even in those who showed a long lasting disappearance of antiphospholipid antibodies. Except for the presence of treated hypertension, this study did not find a particular clinical or biological phenotype for APS patients who relapsed after anticoagulation cessation. Any stopping of anticoagulant in such patients should be done with caution.

Gastric leak after laparoscopic sleeve gastrectomy: early covered self-expandable stent reduces healing time.

BACKGROUND: Laparoscopic sleeve gastrectomy has become a very frequent procedure in bariatric surgery due to its efficacy and simplicity compared to gastric bypass. Gastric staple line leak (1 to 7 % of cases) is a severe complication with a long nonstandardized treatment. The aim of this retrospective study was to examine the success and tolerance of covered stents in its management. METHODS: From January 2009 to December 2011, nine patients with gastric staple line leaks after sleeve gastrectomy were treated with covered stents in our department (seven referred from other institutions). The leaks were diagnosed by CT scan and visualized during the endoscopy. Among the studied variables were operative technique, post-operative fistula diagnosis delay, stent treatment delay, and stent tolerance. In our institution, Hanarostent® (length 17 cm, diameter 18 mm; M.I. Tech, Seoul, Korea) was used and inserted under direct endoscopic control. RESULTS: Stent treatment was successful in seven cases (78 %). Two other cases had total gastrectomy (405 and 185 days after leak diagnosis). Early stent removal (due to migration or poor tolerance) was necessary in three cases. The average stent treatment duration was of 6.4 weeks, and the average healing time was 141 days. The five patients with an early stent treatment (≤ 3 weeks after leak diagnosis) had an average healing time of 99 days versus 224 for the four others. CONCLUSIONS: Covered self-expandable stent is an effective treatment of gastric leaks after sleeve gastrectomy. Early stent treatment seems to be associated with shorter healing time.

Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature.

INTRODUCTION: Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation. METHODS: A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords "adhesion" and "surgery". RESULTS: Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65-75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93-100% of upper abdominal laparotomies and after 67-93% of lower abdominal laparotomies. Nevertheless, only 15-18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm(®)) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction. CONCLUSIONS: The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.

[Fissure syndrome of a gastrointestinal artery pseudoaneurysm in contact with a pseudocyst of the pancreas: rare, but serious complication of chronic pancreatitis]. / Syndrome fissuraire d'un pseudoanevrisme de l'artere gastroduodenale au contact d'un faux-kyste pancreatique: une complication rare mais grave de la pancreatite chronique.

Most pseudoaneurysms (PsA) of the peripancreatic arteries cause direct erosion of the arterial wall from pancreatic enzymes that are usually in contact with or in a pseudocyst (PC). Rupturing is a rare and serious complication (90% mortality if untreated). We report the case of a 56-year-old patient with chronic alcoholic pancreatitis who developed a cephaloisthmic PC, complicated with a PsA of the gastroduodenal artery revealed by pain and deglobulization associated with cholestasis. After a diagnostic scan, emergency selective arteriography with coil embolization was performed. Five days later, hemorrhage recurred and a cephalic duodenopancreatectomy was performed. PsA of the gastroduodenal artery occur in the first 10 years of chronic pancreatitis. They are revealed by abdominal pains and/or gastrointestinal hemorrhage or shock from rupture. A scan with arterial reconstruction provides diagnosis. Arteriography is the most sensitive technique to locate the aneurysm and its branches and to perform selective embolization with coils. The failure rate is between 0 and 23%. Surgical treatment (elective ligation of the artery or partial pancreatic excision) should be limited to when embolisation fails and/or recurrent hemorrhage.

Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of malignant ascites secondary to unresectable peritoneal carcinomatosis from advanced gastric cancer.

AIMS: To review our experience of laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of malignant ascites from advanced gastric cancer in order to discuss benefits, problems and possible indications. METHODS: From June 2000 to May 2003 laparoscopic approach was used to perform HIPEC on five patients affected by malignant ascites secondary to unresectable peritoneal carcinomatosis of gastric origin, in order to associate the benefits of a definitive palliation of ascites with a minimal invasiveness. All patients had ascites related symptoms requiring iterative paracenteses. Intraperitoneal perfusion of mitomycin-C and cisplatin was delivered for 60-90min with an inflow temperature of 45 degrees C. RESULTS: Complete clinical regression of ascites and related symptoms was achieved in all the five patients treated. Intraoperative course was uneventful in all cases. Mean operative time was 181min. No postoperative deaths, related to the procedure, occurred. Only a case of delayed gastric empting was recorded as a minor postoperative complication. CONCLUSIONS: Laparoscopic HIPEC appears to be a safe and effective procedure to treat debilitating malignant ascites from unresectable peritoneal carcinomatosis.

[Precancerous lesions of the gallbladder]. / Lésions précancéreuses de la vésicule biliaire.

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Repercusión del herpes gestationis en los estados materno y fetal / Effect of herpes gestationis on maternal and fetal health

Objetivo: Estudiar la repercusión del herpes gestationis en los estados materno y fetal. Sujetos y métodos: La base de este estudio la constituyen 2 pacientes controladas durante los meses de marzo a octubre de 2003 por el Servicio de Ginecología y Obstetricia del Hospital Universitario Son Dureta de Palma de Mallorca. Ambas fueron fotografiadas en diferentes momentos de su evolución y se les realizaron biopsias de las lesiones que confirmaron el diagnóstico de herpes gestationis. Los controles obstétricos realizados no difieren de los habituales durante una gestación de curso normal. Resultados: La evolución de las pacientes fue favorable tras el uso de corticoterapia. Respecto a las complicaciones fetales descritas, observamos un caso de crecimiento intrauterino retardado y otro de prematuridad. El carácter autoinmune de la enfermedad y su predisposición hereditaria quedan reflejados por el hallazgo de antígenos de histocompatibilidad específicos en una de nuestras pacientes. Conclusiones: El herpes gestationis no es una entidad grave siempre y cuando realicemos un diagnóstico y tratamiento correctos

Objective: To analyze the effect of herpes gestationis on maternal and fetal health. Subjects and methods: Two patients were studied from March to October, 2003 by the Obstetrics and Gynecology Service of Son Dureta University Hospital of Palma, Majorca. Both patients were photographed at various times during the course of the disease. The diagnosis of herpes gestationis was confirmed by biopsy. Their obstetric management did not differ from that in normal pregnancy. Results: Outcome in these patients was favorable after steroid therapy. Regarding fetal complications, low intrauterine growth was observed in one fetus and prematurity in the other. The autoimmune character of the disease and hereditary predisposition were reflected in the finding of specific histocompatibility antigens in one of the two patients. Conclusion: Herpes gestationis is not a serious disease if a correct diagnosis is made and appropriate treatment provided

[Laparoscopic liver surgery for metastases of colorectal cancer: analysis of a monocentric experience]. / Laparoscopic liver surgery for metastases of colorectal cancer: analysis of a monocentric experience.

BACKGROUND: Advances in laparoscopic techniques, refinements of instruments and growth of practical experience in liver surgery during the last decade have prompted some surgeons to develop the laparoscopic approach for hepatic metastases of colorectal cancer (MCRC). AIMS: Primary end points of this clinical study were safety and effectiveness of laparoscopic hepatectomy for MCRC, including early postoperative results and long-term outcomes (overall survival and disease-free survival). DESIGN: Retrospective analysis of data (clinicopathologic, operative, perioperative ad late results) collected in a prospective database. PATIENTS: Between January 1997 and December 2004, 37 non-consecutive (selected) patients underwent curative laparoscopic hepatic resection (n = 42) for MCRC at Montsouris Institut of Paris. Resection was considered when all liver metastases can be totally removed with clear margins, and in absence of nonresectable extrahepatic diseases. Among them were 24 males and 13 females with average ages of 63.4 years (range, 42-78). RESULTS: Metastases were metachronous in 18, multiple in 21, bilateral in 12, and <5 cm in diameter in 30. There were 21 major hepatectomies (n = 3 Couinaud's segments or more), 4 anatomical minor resections, and 12 wedge resections. Mean operative time was 324 +/- 105 mins. Conversion to laparotomy was necessary in 6 patients (16%), due to massive intractable bleeding in 3 patients, multiples adhesions in 1 patient, technical reasons (location of the lesion) in 1 patient, and for presence of localized carcinosis in 1 patient. Portal triad clamping was performed in 6 patients. Mean operative blood loss was 797 +/- 645 ml, and transfusions were required in 4 patients (11%). Clear resection margins (> 5 mm) were observed in 94%. Postoperative mortality was nil. The overall morbidity rate was 35%, with 2 early reoperations due to hemorrhage and postoperative ileus. Overall and disease free survival at 36 months were 87% and 55%, respectively. Five patients who had a recurrence of metastatic liver disease were referred to a second laparoscopic resection. CONCLUSION: This clinical study suggests that laparoscopic liver surgery for metastatic colorectal cancer can be accomplished safely, in selected patients and by experienced surgeons, with good early results and without detrimental consequences on survival.

Extent of oesophageal resection for adenocarcinoma of the oesophagogastric junction.

AIMS: The optimal extent of oesophageal resection and surgical approach in patients treated for adenocarcinomas of the oesophagogastric junction (OGJ) are still uncertain. We report the correlations between resection margin involvement and outcome. METHODS: Patients with positive proximal resection margin (PPRM) and those with negative proximal resection margin (NPRM) were compared. RESULTS: Of 94 patients with macroscopically complete resection, eight were PPRM. There was no difference between the two groups in postoperative mortality or morbidity rates, in anastomotic leakage or in recurrence rates. The median survival in the PPRM group was 11.1 months compared with 36.3 months in the NPRM group (P=0.02). No infiltration was observed in patients whose proximal margin exceeded 7 cm. The extended transthoracic approach was the only prognostic factor for tumours type II (P=0.03, RR=1.4, 95% CI: 1.1-1.8). CONCLUSION: Histologic infiltration of oesophageal resection margin influences 5-year survival rate. In adenocarcinomas of the OGJ that can be treated curatively, a transection with a 8 cm oesophagectomy above the tumour in fresh specimen should be performed, and by thoracoabdominal approach for tumours type I and II.

Surgical management of and long-term survival after adenocarcinoma of the cardia.

BACKGROUND: The choice of surgical strategy for patients with adenocarcinoma of the oesophagogastric junction is controversial. This study was performed to analyse the surgical results of a 20-year experience with these lesions. METHODS: From January 1981 to January 2001, 126 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. The treatment of choice was oesophagectomy for type I tumours, and extended gastrectomy for type II and III lesions. Morbidity, mortality and survival were determined retrospectively. RESULTS: Fifty-six patients (44.4 per cent) had type I tumours, 44 (34.9 per cent) type II and 26 (20.6 per cent) type III. Primary resection was performed in 113 patients (89.7 per cent). Oesophagectomy with resection of the proximal stomach was carried out in 65 patients (51.6 per cent) and extended total gastrectomy with transhiatal resection of the distal oesophagus in 61 (48.4 per cent). In-hospital mortality and morbidity rates were 4.8 and 34.1 per cent respectively. The overall 3- and 5-year survival rates were 40.9 and 25.1 per cent respectively, and were not affected by the surgical approach. Survival was significantly associated with R0 resection, pathological node-positive category, postoperative complications and tumour differentiation. CONCLUSION: Postoperative mortality, morbidity and long-term survival did not appear to be affected by surgical approach. Further prospective studies are needed to confirm the equivalence between transthoracic and transabdominal approaches.

[Adenocarcinomas of the distal esophagus and cardia: surgical management]. / Adénocarcinome du bas oesophage et du cardia: prise en charge chirurgicale.

Adenocarcinoma of the esogastric junction is increasing more rapidly than any other cancer in western country. Patients with carcinoma of the cardia often present at an advanced stage of disease. Accurate preoperative staging of cancer of the cardia need computed tomography, endoscopic ultrasound: laparoscopy is useful for advanced cancer to detect liver and peritoneal metastatis, preventing an unnecessary laparotomy in up to 20% of patients. The Siewert's classification of the cancer of the esogastric junction is accepted internationally: type I: tumor center within the late 5 cm of the distal esophagus, treated with subtotal esophagectomy; type II: located at the esogastric junction, treated with distal esophagectomy and, either proximal or total gastrectomy; and type III: subcardial cancer, treated by extended total gastrectomy. The dominating independent prognostic factors are a complete resection (R0) and the lymph node status (pN0) Expected 5 year survival rate is 30% in patients undergoing surgery with curative intent (R0) and less than 1% in patients undergoing palliative surgery.

[The use of electroconvulsive therapy in acute services at the general hospital]. / Utilización de la terapia electroconvulsiva en una unidad de agudos de hospital general.

GOAL: The aim of the investigation focused on a retrospective analysis of the clinical use of ECT in the Acute Psychiatric Unit of The University Hospital of Guadalajara. METHOD: All patients admitted to our psychiatric unit from 1993 to 1998 and who underwent ECT along their hospitalization, were included in the analysis. Age of the sample ranged from 17 to 79. Several variables were controlled, including technical parameters of ETC application. RESULTS: All patients with a diagnosis of bipolar disorder or schizoaffective disorder showed full remission after ECT. Among patients diagnosed of schizophrenia, 60% experimented full remission and 40% partial remission. In the group of subjects with depression, 66.6% showed full remission, 27.7% partial remission and 5.7% no response. Besides, ETC appeared to be more effective in subjects without psychiatric comorbidity. CONCLUSION: The present retrospective analysis support that ECT still must be considered an effective, useful and safe therapeutic technique. In our review, adverse reactions to ECT have been limited and rare, and mostly reversible.

Utilización de la terapia electroconvulsiva en una unidad de agudos de hospital general / ECT (electroconvulsive therapy) in a General Hospital Psychiatric Inpatient Unit

Objetivo: Nuestro objetivo en este trabajo ha sido hacer un análisis descriptivo retrospectivo de la utilización de la TEC en la Unidad de Hospitalización Breve del Hospital General de Guadalajara. Material y métodos: Se recogen todos los casos comprendidos en el período de tiempo 1993, primer semestre de 1998, de aplicación de TEC en pacientes hospitalizados en nuestra unidad de agudos. Los pacientes tienen edades comprendidas entre 17 y 79 años. Se definen una serie de variables, algunas de ellas inherentes a la propia técnica, otras de ellas al individuo. Resultados: Entre otras variables, se analiza la respuesta a esta técnica agrupando a los pacientes por diagnósticos: esquizofrenia, trastornos esquizoafectivo, manía y depresión. En los pacientes esquizoafectivos y con manía (en el trastorno bipolar), se observó una remisión del 100 por ciento de los pacientes. En el grupo de pacientes esquizofrénicos se apreció una remisión total en el 60 por ciento y una remisión parcial en el 40 por ciento. En los casos de depresión se analizan cuatro subgrupos diferentes, observándose globalmente un 66 por ciento de remisión total y un 27,7 por ciento de remisión parcial. Sólo en un 5,5 por ciento la técnica no resultó eficaz. Se observó también que la respuesta al TEC es mejor en aquellos pacientes en los que no existe otro trastorno comórbido grave. Conclusiones: Este estudio retrospectivo avalaría que la TEC continúa siendo una opción de tratamiento útil, seguro y eficaz. Las complicaciones y efectos adversos relacionados con la TEC han sido pocos, de escasa relevancia clínica, tolerables para el paciente y reversibles (AU)

Skin reactions to hydroxyzine.

Sensitivity to histamine H1-antagonists has mainly been observed with phenothiazine and ethylenediamine, and is very rare with hydroxyzine. We report 3 cases of sensitization to hydroxyzine, which was prescribed to treat urticaria and atopic dermatitis. A generalized maculopapular eruption appeared shortly after taking the drug. Patch tests with Atarax tablet were positive +3, and +2 or +3 with different dilutions of hydroxyzine. Patch tests with ethylenediamine, piperazine and other antihistamines were negative; therefore, there is no cross-allergy. We believe these rapid systemic reactions to hydroxyzine after the initial dose may have been due to prior systemic sensitivity to this drug, which cannot be used topically. Allergy to antihistamines must be considered when cutaneous lesions worsen on such therapy.