Botulinum toxin A (IncobotulinumtoxinA) and pneumoperitoneum image-guided for hernia repair with loss of dominance.

Post-incisional ventral hernia is estimated at 5-30%, when the content of the abdominal cavity migrates to the hernial sac (HSV), with a HSV/abdominal cavity volume ratio > 25%, conditioning systemic changes defined as "loss of domain". A 27-year-old male presented with ventral hernia with loss of domain that required pre-operative preparation techniques, using application of botulinum toxin A (IncobotulinumtoxinA) and pneumoperitoneum, both guided by image. A ventral plasty was performed with adequate return of the viscera to the abdominal cavity. The combination of both techniques seems to be a safe procedure to carry out a tension-free repair.

La hernia ventral postincisional se estima en 5 al 30%, cuando el contenido de la cavidad abdominal migra al saco herniario, con una relación VSH/VCA > 25% condicionando cambios sistémicos se define como "pérdida de dominio". Masculino de 27 años con hernia ventral con pérdida de dominio que ameritó técnicas de preparación preoperatoria, utilizando toxina botulínica A (IncobotulinumtoxinA) y neumoperitoneo, ambos guíados por imagen. Se realizó una plastia ventral con adecuado regreso de las vísceras a la cavidad abdominal. La combinación de ambas técnicas es un procedimiento seguro para realizar una reparación libre de tensión.

[Gastro-bronchial fistula major complication of sleeve gastrectomy]. / Fístula gastrobronquial: complicación mayor de manga gástrica.

BACKGROUND: Gastrobronchial fistula is a rare complication in gastroesophageal surgical procedures. It is difficult to diagnose and handling is complex. Therefore, there have been developments for non-surgical alternatives to obliterate minor fistula mortality. Endoscopic treatment is an option for patients with small fistulas or in serious condition. CLINICAL CASE: A 38 year old woman with evidence of gastrobronchial fistula postoperated of gastric sleeve, diagnosed during the postoperative period due to clinical variegated was initially handled as infectious respiratory symptoms; once the fistulous path was established, the intention was to close the path using endoclips. However, adding hemopneumothorax, drainage tube placement and thoracotomy were required. It was decided to chose a prosthetic esophageal endoscopic management of polytetraflouroethylene and fibrin as last therapy, because the patient had systemic inflammatory response syndrome, with favorable response to endoscopic management. DISCUSSION: Bariatric surgery has shown satisfactory results, however, the complexity of the procedure favors severe complications such as the present case. Gastrobronchial fistulas represent a diagnostic and therapeutic challenge, this is considering from a conservative management to endoscopic procedures, as in our patient. CONCLUSION: Although gastrobronchial fistulas are a rare complication, the use of endoscopy in resolution should be a first class weapon in its management, since it offers a lower morbidity in a patient with habitual respiratory symptoms that are difficult to control, with satisfactory results in the medium and long term.

[Perforated duodenal diverticula. Case report and treatment options]. / Divertículo duodenal perforado. Reporte de caso y opciones de tratamiento.

BACKGROUND: the presence of duodenal diverticula was first described in 1710 by Chromel. Duodenal diverticulum is the second most common site of diverticula in the digestive tract. Anatomically duodenal diverticula are located in 10 to 67% in the second portion of duodenum, and its finding in most cases incidental. About 90% of patients appear asymptomatic, manifesting symptoms mostly once established complications such as: gastrointestinal bleeding and perforation. CLINICAL CASE: 78-years-old woman who attended our Emergency department with dyspnea, moderate epigastralgia, abdominal bloating, constipation and difficulty to pass gas; Laparotomy was performed to identify duodenal diverticulum in the third portion of the duodenum with a perforation of 5 mm in its cupula. It proceeds with diverticulectomy. CONCLUSIONS: The diagnosis of duodenal diverticulum as a cause of acute abdomen must be considered in our differential diagnosis in acute abdomen supported by imaging and endoscopy. The surgical management of duodenal diverticulum, in particular the resection of the diverticulum, remains as the recommendation for treatment with less morbidity and a good recovery.

Antecedentes: los divertículos duodenales los describió por primera vez Chromel en 1710. El divertículo duodenal es el segundo sitio más frecuente de divertículos en el tubo digestivo, el diagnóstico se limita a los casos con complicaciones y síntomas. Los divertículos duodenales se localizan en 10- 67% en la segunda porción del duodeno. Su hallazgo en la mayoría de los casos es incidental. Cerca de 90% de los pacientes cursan asintomáticos y sólo se manifiestan cuando sobrevienen las complicaciones, como la hemorragia digestiva y la perforación. Caso clínico: paciente femenina de 78 años de edad, que acudió al hospital debido a disnea de medianos esfuerzos y epigastralgia moderada, distensión abdominal, constipación y dificultad para canalizar gases. La laparotomía identificó un divertículo duodenal con perforación en su cúpula de 5 mm que dio pie a la realización de la diverticulectomía. Conclusiones: el diagnóstico de divertículo duodenal, como etiología de abdomen agudo, debe contemplarse en cualquier diagnóstico diferencial con cuadro de abdomen agudo, apoyados siempre en la imagenología y endoscopia. El tratamiento quirúrgico del divertículo duodenal, en especial su resección, sigue siendo la recomendación dirigida a la menor morbilidad y mejor recuperación.