Direct portal vein recanalization with stenting associated with embolization of esophagogastric varices in a patient with portal vein thrombosis.

Introduction: Chronic extrahepatic non-tumoral thrombotic portal vein occlusion in non-cirrhotic patients is a rare condition, affecting 5-10% of patients with portal hypertension. Presentation of case: The present study reports the case of a young patient without previous comorbidities who presented with portal hypertension secondary to chronic extrahepatic non-tumoral thrombotic occlusion of the portal vein. He underwent portal recanalization with a 12 × 80 mm nitinol self-expandable stent and embolization of esophagogastric varices with fibrous springs and cyanoacrylate via transparieto-hepatic access. Immediate resolution of the trans-lesion pressure gradient was obtained transoperatively, while complete remission of esophagogastric varices was verified by endoscopic control during outpatient follow-up. Discussion: Chronic portal vein occlusion is associated or not with liver cirrhosis. The chronic phase is characterized by cavernomatous transformation of the portal vein, which consists of the formation of multiple collaterals that bypass the lesion. This phase usually courses with portal hypertension and consequent variceal gastrointestinal bleeding. Decompression of the portal system through direct recanalization (angioplasty with stenting) is one therapeutic options. Conclusion: We conclude that, in the present case, resolving portal hypertension by direct portal recanalization was a good therapeutic option, as it decompressed the portal system while maintaining the hepatopetal flow.

Management of unusual rectal foreign body - Case report and literature review.

INTRODUCTION: Retained rectal objects represent a rare complaint in the emergency room, affecting mainly males between 20 and 40 years, with most objects of a sexual nature, but the examiner must be aware of objects of an unusual nature. PRESENTATION OF CASE: A 54-year-old male patient arrives at the surgical emergency department, with a report of an accident with the insertion of an object via the rectum, a gym dumbbell. Initially opted for transrectal object removal, but with difficulties due to its position. DISCUSSION: Retained rectal objects are a rare complaint in the emergency department, but with an increasingly important occurrence in recent years. Physical examination should include an assessment of the abdomen and digital rectal examination. Imaging tests are mandatory for diagnosis, with abdominal and pelvis radiography being the most requested. Although there is no consensus on the most appropriate removal technique, less invasive initial approaches are recommended, with transanal removal with a 60-75% success rate under local anesthesia. The follow-up after the procedure depends on several factors, and in general, the patient should be kept under observation and attention should be paid to significant changes in the evolution and alterations in the imaging tests. CONCLUSION: The clinical history in these cases can be confusing, due to the patient's fear of reporting the complaints. Radiography is the best initial test, and CT is reserved for cases of suspected complications. Whenever possible, perform the extraction rectally.

Synchronous colorectal and renal cancers: Case report and literature review.

INTRODUCTION: Even though colorectal cancer is one of the most frequent in the world, its simultaneous presence with other neoplasms, such as renal, is still rare in incidence. This article aims to report and expose a literature review of the synchrony of colorectal cancer and renal carcinoma. PRESENTATION OF CASE: A 57-year-old female patient complaining of diffuse abdominal pain that worsened with food and improved with evacuation, especially in the periumbilical region and right iliac fossa, from moderate to strong intensity, starting 1 year ago, worsening in the last 3 months. An abdominal CT scan was performed, showing a lesion in the right kidney and a narrowing of the ascending colon lumen. Due to the possibility of cure, we opted for right colectomy and right nephrectomy at the same surgery. DISCUSSION: Synchronous tumors are neoplasms in which the diagnostic interval is up to 6 months, and must be differentiated from metachronic neoplasms and even metastases between tumors. The incidence of synchronous colorectal and renal cancer is rare but appears to be divergent. CONCLUSION: The presence of synchronous tumors can be evidenced in imaging tests, such as CT scan, but appropriate diagnostic tests for each neoplasm, such as colonoscopy, should not be ruled out. The treatment of choice must be surgery, when possible, with the options of conventional access, videolaparoscopic and robotic surgery.

Thoracic foreign body management after penetrating chest trauma by chainsaw in the Amazon countryside: A case report.

INTRODUCTION: Accidents involving chainsaws are not uncommon in trauma care and may present as penetrating injuries with retention of a foreign object in the patient's chest. The current literature, however, does not present a consensus on the best way to approach these cases. PRESENTATION OF CASE: Male patient, 46-year-old man, born in Amazonas countryside, brought to the city of Manaus with a penetrating injury resulting from an accident with a chainsaw and retaining a 2cm sawtooth in his chest, six days after the event. After laboratory and imaging tests, as well as pre-operative preparation, an open thoracotomy was realized, the object was removed, and the patient was placed under a thoracostomy tube. DISCUSSION: The diagnosis of chainsaw incidents is generally described in the literature as post-mortem, mainly due to the inappropriate use of the equipment. Surgical removal of a foreign body is indicated in most cases, except when it is peripheral or when there is some impossibility. Early surgical treatment benefits the patient, with lower mortality and morbidity. CONCLUSION: In view of the absence of consensus and guidelines to the approach of thoracic injury with foreign body retention, it is up to the surgeon to evaluate the best conduct in each case and according to the available resources.

Rectosigmoid transition perforation by ingá (Inga laurina) seeds in the Brazilian amazon: Case report and surgical treatment.

INTRODUCTION: Foreign body ingestion is a common clinical scenario found in clinical practice. Perforations related to foreign bodies are rare, but they can present as a serious condition in emergency surgery services. The most common sites of perforation are angled areas, such as: ileocecal valve, sigmoid colon, duodenojejunal flexure and small intestine. We are going to describe a rare case of extensive perforation of rectosigmoid transition, without associated obstructive clinical picture, related to voluntary ingestion of foreign body caused by multiple seeds of a typical amazon fruit. PRESENTATION OF CASE: This case report describes the presentation and management of a 46-year-old man who presented signs of acute perforating abdomen, without obstructive condition, after ingestion of foreign body. Imaging examination revealed the presence of foreign bodies with signs of intestinal perforation. Exploratory laparotomy was performed to treat the lesion and remove foreign bodies. DISCUSSION: Bowel perforation by a non-sharp foreign body is a rare complication of object ingestion. Object shape, quantity, narrowing of gastrointestinal tract are factors that can favor perforation. The clinic is not very specific, usually preceded by when obstructive or sub occlusive, and the clinical history is relevant for diagnostic formulation. Regions and cultures with a high intake of food with seeds may constitute an extra risk factor. CONCLUSION: The importance of alerting surgical teams to the possibility of bowel perforation without associated occlusive conditions caused by multiple non-sharp seeds is highlighted, as well as the need for early treatment aiming at favorable clinical outcome.

Gastric metastasis from breast cancer in male patient - Case report and literature review.

INTRODUCTION: Male breast cancer has a low incidence, and its metastases are considered even rarer and a sign of seriousness for the patient. Breast metastases are difficult to diagnose even in female patients, with few cases of gastric metastasis described in the current literature. PRESENTATION OF CASE: Male patient, 54 years old, obese, diagnosed with breast cancer for 8 years, underwent 5 years of cancer follow-up. After this period, he began to experience epigastric pain and weight loss, among other symptoms. Endoscopy was performed, showing rounded elevated lesions with central depression. After anatomopathological and biochemical tests, a diagnosis of differentiated carcinoma as a metastasis of breast origin was concluded. DISCUSSION: MBC is rare when compared to the incidence in females. Its risk factors differ between genders, and due to its rarity, there are few studies in the male population. This fact makes the evaluation of metastases more difficult. Gastric metastasis has a very low incidence even in women, approximately 8.9% of all breast cancer metastasis's locations. Other pathologies can mimic GM, always associating anatomopathological and biochemical tests. Oncological follow-up must always be carried out, and the possibility of screening must be evaluated. CONCLUSION: Despite the rare incidence and little information in the literature, the association between MBC and GM should be considered. Currently, there is no guidance for conducting systematic screenings and treatment is usually palliative due to the severity of the disease.

Gallstone ileus associated with cholecystogastric fistula: Case report, diagnosis and surgical treatment.

INTRODUCTION: Gallstone Ileus is a rare complication of cholelithiasis, associated with multiple episodes of cholecystitis, with the formation of adhesions and fistulas between the gallbladder and adjacent organs. Its diagnosis is difficult, requiring complementary imaging tests such as computed tomography or radiography. PRESENTATION OF CASE: Female patient, with intestinal obstruction for 7 days, associated with abdominal pain and previous episodes of pain in the right hypochondrium for 3 months. Abdominal CT scan identified aerobilia, gallstone impacted in the ileocecal valve and small loop dilatation, in addition to a probable cholecystogastric fistula. Opted for exploratory laparotomy, enterolithotomy and fistula correction in one surgical time. DISCUSSION: Gallstone ileus is rare among the complications of cholelithiasis, in addition to the fact that cholecystogastric fistula is associated with gastric pylorus obstruction and not impaction on the ileocecal valve. Imaging tests are useful to complement the diagnosis, and if Rigler's triad is present, the suspicion of gallstone ileus is increased. The presence of fistula between the gallbladder and stomach presents a frequency between 0 and 13.3%. There is no gold standard treatment for gallstone ileus, but surgery options for each type of patient and severity level. CONCLUSION: There is no definitive protocol for optimal surgical treatment for biliary ileus, but the possibility of enterolithotomy associated with cholecystectomy and fistula correction can be evaluated in selected patients.

Boari-Flap reconstrution due to a total ureteral avulsion in a patient with ipslateral ureterolithiasis and contralateral renal nodule.

The ureteral avulsion during ureterolithotripsy (URS) occurs due to the sudden movement of the optical device or endoscopic extractor either in its removal or insertion, associated with a probable previous lesion in the ureter wall, causing a vital fragility area. A 52-year-old male patient with, an obstructive calculus of 9 mm was found in the left middle ureter, and a heterogeneous hypervascular nodule located in the right kidney, suggesting neoplasia. During procedure with rigid ureteroscopy with ureteroscope removal, due to the pressure of the device and tissue fragility, there was total ureter avulsion.

Delayed diaphragmatic hernia after open trauma with unusual content: Case report.

INTRODUCTION: Post-traumatic diaphragmatic hernias are not commonly diagnosed immediately after the initial trauma. There is a greater prevalence of left hernias due to the fragility or injury in diaphragm muscle and the lack of solid and fixed structures on the left side. PRESENTATION OF CASE: A male patient, 30 years old, he was admitted to the emergency department presenting diffuse abdominal pain, vomiting, dyspnea, pain in the left hemithorax with worsening during forced inspiration. After performing X-ray and computed tomography (CT), the presence of organs in the abdominal cavity outside the usual position was evidenced and with discrete deviation. Immediate surgery was performed with posterolateral thoracic access through the sixth left intercostal space combined with left subcostal access. Initially, it was found jejunum, ileum and left colonic flexure and accessory spleen filling the hernial sac. DISCUSSION: This report is the first case to report two accessory spleens in manual reduction of herniation between thoracic and abdominal cavities after trauma and percutaneous perforation. The splenectomy performed in both organs occurred due to their advanced ischemia that was due to reduced vascularity. CONCLUSION: The presence of the reported accessory spleen inside the thoracic cavity is only a possible variation within the possibilities in cases of diaphragmatic hernias, which does not modify the surgical procedure in a relevant way.

Late cholestatic syndrome due to previous perforating trauma: Case report.

INTRODUCTION: The presence of a foreign body obstructing the bile duct may appear through a typical picture of cholangitis, usually caused by the presence of gallstones. PRESENTATION OF CASE: Male patient, 31 years old, involved an in accident with gunshot in 2006, injured in the abdominal region. Evolved to a picture of intense pain in the right hypochondrium, mainly after fat meals, without irradiation 12 years after being injured. Presented jaundice episode associated to fecal acholia, choluria, pruritus and sporadic fever. It was diagnosed cholangitis due to the foreign body like a bullet, located in the hepatic duct after tomography performed for investigation. The conduction of the case is described next. DISCUSSION: Cholestatic syndrome caused by gun bullet in a prior event to the symptoms is a rare event in the literature. Total, there are 8 case reports of bullets found in bile ducts with distinct evolution time among themselves. The first exam will not necessarily identify the bullet, but it simplifies the visualization of the bile ducts dilation, characterizing obstruction. CONCLUSION: The presence of a foreign body in the bile ducts is well reported in literature, and it is directly dependent on previous history. We should always avoid using cholangioresonance in dubious cases. To keep the ERCP as initial treatment is recommended due to the advances on the procedure quality, but in more severe cases or lack of resources, the surgical exploration is still indicated.

Surgical treatment of kidney tumor on a patient with second case of staghorn calculus and associated renal hydronephrosis: case report.

Staghorn, struvite or coral calculus are the ones that completely or partially occupies the renal pelvis and branches to the renal calices. The presence of renal calculi of any kind in the urinary tracts is related to the appearing of malign tumor in the kidneys, especially in the absence or failed treatment. A male patient, 51 years old, native of Manaus, reports about dysuria and polyuria associated with constant fever episodes and urinary tract infections with improvement by using several antibiotics but returning the symptoms after suspending it. The patient return was in a month and no improvement of the pain in the patient's feeling, with the tomography image tests result showing atrophy in the right kidney, which presents dilatation of the collector system, that it's filled with material with density varying between thick liquid and soft parts (average of 45 UH), in addition to calculus in the pelvis and ureteropelvic junction, suggesting a pattern for xanthogranulomatous pyelonephritis and matching previous history of right staghorn calculus. The association between kidney cancer and staghorn calculus should be consider through the treatment. Patients with renal diseases of severe prognosis in both kidneys must be kept under constant surveillance by the urology and nephrology team, the association of both clinics is essential to a fortunate ending like the case reported.

Large verrucous penis cancer in a young patient in the Brazilian Amazon: Case report and discussion on the region's reality.

INTRODUCTION: Penile cancer is a rare malignant tumour top in urology, especially in developed countries or in a favourable cultural habit. However, in developing countries or with a low socio-economic population, the incidence increases considerably, as does the stage at which the patient arrives for the first care. CASE PRESENTATION: Male patient, 20 years old, from the interior of Amazonas - Brazil, has been referred to a Urological Service in the Emergency Room due to a vegetative lesion of approximately 10 centimetres, with an ulcerated centre and irregular borders in penile glans. An incisional biopsy was performed, which revealed invasive squamous cell carcinoma and was referred to the elective surgery service. CONCLUSIONS: The socioeconomic condition of the population influences in a relevant way in cases in the Amazon region, with little and difficult access to preventive information and to the public health system, mainly in the interior of the state. Young patients tend to maintain the confidentiality of the picture that leads to the progression of the disease, with negative outcomes, requiring intense psychological monitoring.

Videolaparoscopic treatment of total migration of double j stent to renal pelvis as a complication of rigid ureterolitotripsy in a university hospital at Amazon.

The insertion of a double-j catheter in patients with urinary lithiasis is currently important because it reduces the chances of obstructive complications such as hydronephrosis and renal functional loss. The following case aims to show the patient evolution which presented the complete migration of the catheter to the renal pelvis and how it could complicate its prognosis. Placing a dual-catheter for treatment of lithiasis is a routine procedure in urology services but is not beyond complications during the process. Even with exhaustive complementary imaging exams, we must maintain a constant evaluation of the patient.

The alternative model of silicone for experimental simulation of suture of living tissue in the teaching of surgical technique.

PURPOSE: To develop a silicone alternative model of tissue suture simulation to be used in the teaching of surgical technique. METHODS: Twelve alternative models of silicone for tissue suture simulation were manufactured and implemented as a tool for suture pattern training of undergraduate medical students of Universidade Federal do Amazonas. Forty-eight students participated in the research. The evaluation of the proposed model was done through a questionnaire using the Likert scale, in order to verify the student satisfaction index of the alternative resource and its performance as opposed to the model historically used in the discipline, which is to suture in cloths. RESULTS: The alternative model showed satisfactory results, especially with respect to the structural aspect, such as, better perception of anatomical planes, handling and transport. About 89.58% of positive concordant responses demonstrating expressive approval for incorporation of a complementary form of the alternative methodological proposal of the discipline of surgical technique. CONCLUSIONS: The model developed for experimental simulation of tissue sutures has proved to be a fully feasible alternative method for the training of this surgical skill. It is a simple, reproducible and low-cost model.

The alternative model of silicone for experimental simulation of suture of living tissue in the teaching of surgical technique

Abstract Purpose: To develop a silicone alternative model of tissue suture simulation to be used in the teaching of surgical technique. Methods: Twelve alternative models of silicone for tissue suture simulation were manufactured and implemented as a tool for suture pattern training of undergraduate medical students of Universidade Federal do Amazonas. Forty-eight students participated in the research. The evaluation of the proposed model was done through a questionnaire using the Likert scale, in order to verify the student satisfaction index of the alternative resource and its performance as opposed to the model historically used in the discipline, which is to suture in cloths. Results: The alternative model showed satisfactory results, especially with respect to the structural aspect, such as, better perception of anatomical planes, handling and transport. About 89.58% of positive concordant responses demonstrating expressive approval for incorporation of a complementary form of the alternative methodological proposal of the discipline of surgical technique. Conclusions: The model developed for experimental simulation of tissue sutures has proved to be a fully feasible alternative method for the training of this surgical skill. It is a simple, reproducible and low-cost model.