Small bowel obstruction caused by pericaecal hernia resolved with a laparoscopic approach.

Small bowel obstruction from internal hernias is a familiar pathology for the surgeon, with an incidence of 0.5-5.8%. However, pericaecal hernia is a very uncommon type of internal hernia. Diagnosis and early treatment are essential to avoid strangulation and necrosis of the incarcerated small bowel. We report a case of an 84-year-old woman with no previous history of abdominal surgery who came to our hospital having endured 6 hours of abdominal pain and vomiting. Following physical examination and computed tomography, a diagnosis of small bowel obstruction caused by pericaecal hernia was made and emergency surgery was performed. The hernia was successfully reduced with a laparoscopic approach. Although pericaecal hernia is a rare disease, surgeons should bear it in mind as a differential diagnosis in small bowel obstruction.

Femoral hernia containing the right fallopian tube: chronic pain with menstruation.

Femoral hernias represent less than 10% of groin hernias and appear mainly in adult women; incarceration is more usual than in other hernias. Content found within the sac is commonly small bowel or omentum. Other anatomical structures, such as appendix, bladder, Meckel's diverticulum, ectopic testis, stomach and gynaecological organs are extremely unusual. A 48-year-old woman presented with intense right groin pain over 48 hours. Her past medical history revealed periodical moderate right groin pain coincident with her menstrual cycles, usually self-limited. No abdominal symptoms or fever were present. On physical examination, an incarcerated right femoral hernia was suspected. Subsequently abdominal ultrasound revealed a right femoral hernia containing an echogenic structure with conserved vascularisation. The patient underwent an emergency surgery. During the procedure the right fallopian tube and several small cysts were discovered as the hernia sac contents. As no ischaemic signs were observed, and the sac was sutured and reduced. Femoral hernioplasty was accomplished with polypropylene mesh. The postoperative course was uneventful and the patient was discharged within 24 hours. After an exhaustive literature review, we have found few cases reporting the presence of fallopian tube in adult women with femoral hernia, but none described a recurrent groin pain coinciding with menstruation, as in this case.

Laparoscopic hemi-splenectomy: a valid option in selected cases such as epidermoid cyst.

Splenic cysts are a rare pathology, which can be classified as true (25%) or pseudocysts (75%). Total splenectomy has been the treatment of choice, particularly in recent times with the advent of the laparoscopic approach. However, as the spleen is an organ with multiple immunological functions, the laparoscopic partial splenectomy is an alternative, which is technically difficult but effective. We present a case of a 26-year-old woman with incidental evidence of a splenic cyst in an abdominal ultrasound scan. We performed a laparoscopic partial splenectomy to preserve the function of the spleen because of the patient's youth. Laparoscopic partial splenectomy allows the effective removal of lesions and preservation of splenic function. Although more research is needed to clarify the most effective approach, this case is further evidence that this surgical approach may be beneficial for selected patients.

Incidence of hepatic artery variations in liver transplantation: does it really influence short- and long-term results?

BACKGROUND: Some variations of hepatic artery, which show 30% incidence, must be taken into account to avoid damage to the liver transplant during harvesting, we analyzed the incidence of variations and their influence on postoperative results. PATIENTS AND METHODS: We performed a retrospective study of 325 liver transplantation between 2001 and December 2011. RESULTS: Variations in the hepatic artery were detected in 91 transplantations (32%) including 29 donors (8.9%), 57 recipients (17.5%), and 5 both (1.5%). The main variation among donors was a right hepatic artery originating from the mesenteric artery (38.2%), and a left hepatic artery from the left gastric artery (35.3%). Recipients showed the same distribution: RHA-UMA (right hepatic artery from upper mesenteric artery) (38.7%) and LHA-LGA (left hepatic artery from left gastric artery) (12.9%). 48.5% of donor hepatic variations did not need bench reconstruction, but all RHA-UMA required it mainly due to the donor gastroduodenal artery (7; 58%) We did not observe significant difference in cold or warm ischemia time, surgical time, red blood cell requirement, postoperative mortality, or overall survival when there was or was not an arterial anomaly. But arterial complications were more frequent in cases where there were recipient anomalies or both versus without anomalies or with donor anomalies (20%, 7,8%, 0%, 5,6%; P = .06). Donor RHA-UMA was associated with worse overall survival (69, 2%; P = .07) and longer cold ischemia time and red blood requirement. Bench reconstruction held to longer cold ischemia time and blood cell requirements (P = .01) and shorter overall survival (82.4%). RHA-UMA was associated (P = .08) with worse actuarial survival and a needed for bench reconstruction (P = .01). CONCLUSION: One must be careful during liver harvest to detect hepatic artery variations to avoid damage. Hepatic artery anomalies do not influence liver transplant results except for the presence of an RHA from the UMA with a need for bench reconstruction.

Transplantation for acute liver failure: report of results in the region of Castilla y Leon (Spain) after 10 years of activity.

Acute liver failure is an uncommon disease but its overall mortality rate is still high without liver transplantation, which is the treatment of choice for patients achieving certain criteria. We have reported herein the experience and retrospectively analyzed results of liver transplantation for acute liver failure since the beginning of activity of our group, which is the only one in the region of "Castilla y Leon" (Spain). In 10 years, 14 patients underwent emergency transplantation among an overall series of 325 subjects. The patients were generally young men and women; the average wait list time was 2.14 days. The most common etiology was toxic exposure (no cases were related to acetaminophen overdose), followed by viral infection (all because of acute hepatitis B). Our posttransplant outcomes were: perioperative mortality, 0%; posttransplant in-hospital mortality, 14%; and 1-y, 3-y, and 5-year survival rates of 77.1%, 64.3%, and 64.3% respectively. Retransplantation rate was 7%. A major morbidity occurred in four patients: one primary dysfunction, one hyperacute rejection due to ABO blood group-incompatibility requiring retransplantation, two arterial complications, and two biliary leakages. Our outcomes of emergency transplantation were similar to those reported by both the European and Spanish Liver Transplantation Registries, despite the small number of patients.

Eight years experience with liver transplantation in Rio Hortega hospital.

OBJECTIVES: We sought to evaluate our transplant series in light of the parameters outlined in the quality criteria established by the Spanish Hepatic Transplant Society (Sociedad Española de Trasplante Hepático [SETH]). METHODS: We retrospectively analyzed 240 hepatic transplantations performed in 223 patients from November 2001 to December 2009. RESULTS: Among the series, 57% were in Child class C, 50% had cirrhosis without hepatocellular carcinoma, and 32% had this neoplasm. The most common cause for the illness was alcohol, followed by a virus, namely hepatitis C virus in 76% of cases. The average waiting list time was 45.14 days. The total graft ischemia averaged 460 minutes (range, 265-937). The 4.1% (n = 10), incidence of an urgent retransplantation was mainly due to primary graft failure or arterial thrombosis. During the perioperative period the mortality rate was 2.5% (n = 6) and the 1-month mortality rate was 6.6% (n = 16). The raw survival rates at 1, 3, and 5 years after the operation are 85%, 78%, and 72%, respectively. CONCLUSION: Our perioperative as well as the long-term results fall within the quality standards established by SETH.

Incidence, management, and results of vascular complications after liver transplantation.

INTRODUCTION: Vascular complications show an 8%-15% incidence after liver transplantation and represent an important cause of mortality. An aggressive policy is necessary for an early diagnosis and treatment. PATIENTS AND METHODS: From 2001 to 2009, we performed 240 liver transplantations in 232 patients. We employed Doppler ultrasonography on days 1 and 4 as well as before hospital discharge and always try a radiological approach. RESULTS: The incidence of vascular complications was 7.2% (n = 18) including arterial (n = 12, 4.8%) of early thrombosis (n = 4), late thrombosis (n = 4), and stenosis (n = 4) or portal (n = 3; 1.2%) of thrombosis (n = 2) or stenosis (n = 1); or caval complications (n = 3, 1.2%). Radiologic therapy was effective in 1 patient with arterial stenosis, in the 3 patients with portal complications, and in 2 patients with caval complications. All patients with early thrombosis and 2/4 with late thrombosis required retransplantation. Surgical treatment was effective in 1 patient with late thrombosis, 3 with stenosis, and 2 with caval complications. The overall mortality rate was 16.6%; 2 patients with arterial complications and 1 with a caval complications. CONCLUSION: Vascular complications, mainly artery complications, represent serious problem after liver transplantation, which often requires retransplantation. With an aggressive policy of diagnosis and treatment, we can decrease the mortality rate from these adverse events.

Resultados a medio largo plazo de la técnica de han en tratamiento de pacientes con varices y trombosis porto-espleno-mesentérica / HAN technique in the treatment of patients with varieces and thrombosis of portal, mesenteric and splenic veins. Results a long term

INTRODUCCIÓN. Una de las complicaciones más graves de la hipertensión portal es el sangrado digestivo por varices. Cuando la terapia endoscópica fracasa es preciso recurrir a la cirugía, con técnicas como las derivaciones o las devascularizaciones. CASO CLINICO 1: varón de 49 años con cirrosis enólica y episodios repetidos de sangrado por varices esofágicas y fúndicas. Trombosis de las venas porta, mesentérica superior y esplénica asociado a cavernomatosis portal. Se realizó devascularización esofagogástrica, fundectomía y esplenectomía. CASO CLINICO 2: mujer de 57 años con hipertensión portal por fibrosis hepática congénita. Presenta episodios repetidos de hemorragia digestiva por varices esofágicas, subcardiales y fúndicas. El tratamiento con betabloqueantes y endoscópico había fracasado. Shunt porto-cava y el TIPS (Shunt portosistémico intrahepático transyugular) no fueron capaces de controlar el sangrado por varices. Posteriormente presenta trombosis del eje espleno-portal. Finalmente se realiza devascularización esofagogástrica, fundectomía y esplenectomía. DISCUSIÓN. La endoscopia es la primera opción del tratamiento de las varices esofagogástricas. La devascularización esofagogástrica (procedimiento de Sugiura) surgió como una alternativa a las derivaciones quirúrgicas, pero tiene importantes complicaciones que aumentan la mortalidad. La fundectomía asociada a la devascularización constituye una buena alternativa,en pacientes con varices del fundus (AU)

INTRODUCTION. The digest variceal bleeding is one of the most serious complications of portal hypertension. If endoscopic therapy fails come be necessary to surgical treatment with portosystemical shunt or esophagogastric devascularization. CLINIC CASE 1. We present the case of a 49-year-old man with alcoholic cirrhosis. He had continuous episodes by oesophageal and fundal variceal bleeding. He had splenomesoportal thrombosis associated with development caverns in the portal system. We performed a periesophagogastric devascularization, fundectomy and splenectomy. CLINIC CASE 2. A 57-year-old with portal hypertension by congenital hepatic fibrosis. She had episodes of recurrent bleeding by oesophageal, subcardial and fundal variceal. Beta-blockade and endoscopy therapy had failed. The potacaval shunt and TIPS could not achieve definitive control of variceal bleeding. She had splenomesoportal thrombosis later. Finally we performed a periesophagogastric devascularization, fundectomy and splenectomy. DISCUSSION. The endoscopic therapy is the first option by treatment of esophagogastric varices. The periesophagogastric devascularization (Sugiura procedure) came up as another option to the surgical shunt, but has important complications that increase the mortality rate. The fundectomy related to devascularization is a good alternative especially for patients with fundal variceal (AU)

Profilaxis de la enfermedad tromboembólica perioperatoria en cirugía general / Prophylaxis of perioperative thromboembolic disease in general surgery

Objetivo. Revisar el estado actual de la incidencia, factores de riesgo y profilaxis de la enfermedad tromboembólica perioperatoria en los pacientes sometidos a cirugía abdominal. Métodos. Esta revisión está basada en una búsqueda de la bibliografía en la base de datos MEDLINE, sobre la enfermedad tromboembólica perioperatoria en pacientes sometidos a cirugía general y del aparato digestivo, así como en la experiencia de los autores. Resultados. La incidencia de trombosis venosa profunda en pacientes sometidos a cirugía abdominal sin profilaxis antitrombótica oscila entre el 20 y el 30 por ciento y la del embolismo pulmonar entre el 0,3 y el 0,8 por ciento. Los factores de riesgo más importantes son: edad mayor a 40 años, obesidad, antecedente de enfermedad tromboembólica y ciertas enfermedades asociadas. La profilaxis con heparina no fraccionada disminuye la incidencia de trombosis venosa profunda y embolismo pulmonar al 7 y 0,1, respectivamente. Las heparinas de bajo peso molecular son tan efectivas como la no fraccionada y se asocian con menor riesgo de hemorragia y hematomas en la zona de punción. Conclusiones. La profilaxis de la enfermedad tromboembólica perioperatoria en cirugía general está indicada en los pacientes de riesgo moderado y alto. Las heparinas de bajo peso molecular se consideran los fármacos de elección para dicha profilaxis. Las heparinas de bajo peso molecular de segunda generación, entre ellas la bemiparina, se perfilan como el futuro de la profilaxis, si bien se precisan más estudios prospectivos que corroboren los resultados de los ya realizados (AU)