[Adult intestinal no rotation]. / No rotación intestinal en adultos: causa infrecuente de abdomen agudo oclusivo.

90% of cases of intestinal obstruction caused by intestinal malrotation occur in children under 1 year of age, being very uncommon in adults. A female patient of 27 years of age consults with abdominal pain, vomiting, abdominal distention, dehydration and signs of severe malnutrition. After EGDS, CT scan, and 48 hours of clinical expectation, surgical intervention was decided with diagnosis of high intestinal obstruction. Intraoperative finding was no intestinal rotation at all. Ladd´s technique was performed together with prophylactic appendectomy. Postoperative evolution was favorable. The rare presentation in adults motivates the presentation of this case.

Causa infrecuente de abdomen agudo hemorrágico / Rare cause of acute abdomen bleeding

La rotura espontanea de vasos uterinos es una rara causa de abdomen agudo hemorrágico durante el embarazo y una complicación potencialmente mortal. Las manifestaciones clínicas son: dolor abdominal súbito, shock hipovolémico y caída de hematocrito. Objetivos: Presentación de causa infrecuente de abdomen agudo hemorrágico. Reporte de Caso: Se presenta un caso de una mujer de 36 años primigesta, con embarazo de 27 semanas, con abdomen agudo, sin antecedentes traumáticos y signos de shock hipovolémico. Ecografía abdominal con líquido libre en cavidad. En laparotomíaexploradora se halla laceración de vena uterina derecha, se realiza hemostasia directa y cesárea de urgencia por bradicardia fetal severa. Discusión: Debe realizarse un correcto diagnóstico diferencial dado que el tratamiento de la rotura espontanea de los vasos uterinos es el manejo urgente del shock hipovolémico y la intervención quirúrgica a la brevedad...

Spontaneous rupture of uterine vessels is a rarecause of acute abdomen bleeding during pregnancy and apotentially fatal complication.Clinical manifestations include sudden abdominal pain,hypovolemic shock and fall of hematocrit.Objectives: Introducing rare cause of acute abdomen bleeding.Case Report: We presents case of a woman aged 36 with 27weeks pregnancy (first one), acute abdomen, without traumatichistory WITH signs of hypovolemic shock. Abdominal ultrasoundwith free fluid in the cavity. At laparotomy we found laceration ofthe right uterine vein, performing direct hemostasis andemergency cesarean for severe fetal bradycardia.Discussion: We have to make sure of doing a correct differentialdiagnosis because the treatment of spontaneous rupture of theuterine vessels is urgent for management of hypovolemic shockand surgery should be performed promptly...

La presión del CO2 intraoperatorio y su relación con la omalgia; estudio prospectivo aleatorio / Intraoperative CO2 pressure and its relationship with omalgia (randomized prospective trial)

Introduccón: La colecistectomía laparoscópica es considerada desde principios de los años noventa como el tratamiento de referencia de la litiasis vesicular. Uno de sus beneficios demostrados en comparación con el abordaje convencional es la mejoría significativa del bienestar postoperatorio. Creemos que la presión de insuflado abdominal puede influir en la incidencia de dolor postoperatorio, por lo que el objetivo de este estudio fue investigar la influencia de la presión del neumoperitoneo en la aparición de omalgia. Material y Metodos: Se realizó estudio prospectivo, con asignación aleatoria, a dos grupos: A n= 60 pacientes insuflados a una presión 12 mmHg y un grupo B n=40 pacientes insuflados a una presión de 10 mmHg; entre julio de 2010 a julio de 2011. Criterios de inclusión: pacientes adultos con indicación de colecistectomía. Criterios de exclusión; menores de 18 años, embarazadas, pacientes con enfermedades crónicas que requieren de administración de analgésicos (artritis reumatoidea, enfermedades oncológicas, etc), tratamiento quirúrgico previo, quienes se rechacen participar del estudio. Se utilizó el mismo insuflador con flujo constante (máx. 20 l/m.), y el mismo equipo laparoscópico. El neumoperitoneo se realizo con aguja de Veress en todos los casos. Colocación de trocares con técnica americana. La omalgia fue evaluada a las 12 hs de finalizada la cirugía. Resultados: Se incluyeron 120 pacientes, sometidos a colecistectomías laparoscópicas programadas. Ningún paciente requirió de conversiones. Con una edad media de 51 años, con un rango entre 16 y 82 años, La incidencia de omalgia fue del 40% para el grupo con presiones de insuflado de 10 vs 60% para el grupo con presiones de insuflado de 12 mmHg, P =0,006. La incidencia de omalgia no fue diferente según sexo, 20% de las mujeres vs el 25 % de los hombres (p=0,657), ni para edad, comorbilidad, hábito físico y/o cirujano...

Introduction: Since early 1990s, laparoscopic cholecystectomy is considered as the standard of care for gallstones. One of its demonstrated benefits in comparison with the conventional approach is the significant improvement of post-surgery well-being. We believe that abdominal insufflation pressure may affect the incidence of postoperative pain, and thus, the objective of this trial was to investigate the influence of pneumoperitoneum pressure in the incidence of shoulder pain. Material and Methods: A prospective trial was performed between July 2010 and July 2011, with random allocation into two groups: A n=60 patients with insufflation pressure of 12 mmHg, and B n=40 patients with insufflation pressure of 10 mmHg. Inclusion criteria: adult patients with indication for cholecystectomy. Exclusion criteria: patients under the age of 18 years old, pregnant women, patients with chronic diseases which require pain relievers (rheumatoid arthritis, oncologic diseases, etc.), previous surgery and patients who refuse to participate in the trial. The same insufflator was used with constant flow (20 l/m max) and the same laparoscopic device. Veress needle was used for pneumoperitoneum in all cases. Trocars were positioned using the American technique. Omalgia was assessed 12hs. after surgery. Results: The trial included 120 patients, who had undergone scheduled laparoscopic cholecystectomies. None of the patients required conversion to conventional surgery. With a mean age of 51 years old, ranging from 16 and 82 years of age, the incidence of omalgia was 40% for the group with 10 of insufflation pressure vs. 60% for the group with 12 mmHg of insufflation pressure, P=0.006. The incidence of shoulder pain was not different according to sex –20% women vs. 25% men (p=0.657)– nor for age, co-morbidity, fitness and/or surgeon...

La presión del CO2 intraoperatorio y su relación con la omalgia; estudio prospectivo aleatorio / Intraoperative CO2 pressure and its relationship with omalgia (randomized prospective trial)

Introduccón: La colecistectomía laparoscópica es considerada desde principios de los años noventa como el tratamiento de referencia de la litiasis vesicular. Uno de sus beneficios demostrados en comparación con el abordaje convencional es la mejoría significativa del bienestar postoperatorio. Creemos que la presión de insuflado abdominal puede influir en la incidencia de dolor postoperatorio, por lo que el objetivo de este estudio fue investigar la influencia de la presión del neumoperitoneo en la aparición de omalgia. Material y Metodos: Se realizó estudio prospectivo, con asignación aleatoria, a dos grupos: A n= 60 pacientes insuflados a una presión 12 mmHg y un grupo B n=40 pacientes insuflados a una presión de 10 mmHg; entre julio de 2010 a julio de 2011. Criterios de inclusión: pacientes adultos con indicación de colecistectomía. Criterios de exclusión; menores de 18 años, embarazadas, pacientes con enfermedades crónicas que requieren de administración de analgésicos (artritis reumatoidea, enfermedades oncológicas, etc), tratamiento quirúrgico previo, quienes se rechacen participar del estudio. Se utilizó el mismo insuflador con flujo constante (máx. 20 l/m.), y el mismo equipo laparoscópico. El neumoperitoneo se realizo con aguja de Veress en todos los casos. Colocación de trocares con técnica americana. La omalgia fue evaluada a las 12 hs de finalizada la cirugía. Resultados: Se incluyeron 120 pacientes, sometidos a colecistectomías laparoscópicas programadas. Ningún paciente requirió de conversiones. Con una edad media de 51 años, con un rango entre 16 y 82 años, La incidencia de omalgia fue del 40% para el grupo con presiones de insuflado de 10 vs 60% para el grupo con presiones de insuflado de 12 mmHg, P =0,006. La incidencia de omalgia no fue diferente según sexo, 20% de las mujeres vs el 25 % de los hombres (p=0,657), ni para edad, comorbilidad, hábito físico y/o cirujano... (AU)

Introduction: Since early 1990s, laparoscopic cholecystectomy is considered as the standard of care for gallstones. One of its demonstrated benefits in comparison with the conventional approach is the significant improvement of post-surgery well-being. We believe that abdominal insufflation pressure may affect the incidence of postoperative pain, and thus, the objective of this trial was to investigate the influence of pneumoperitoneum pressure in the incidence of shoulder pain. Material and Methods: A prospective trial was performed between July 2010 and July 2011, with random allocation into two groups: A n=60 patients with insufflation pressure of 12 mmHg, and B n=40 patients with insufflation pressure of 10 mmHg. Inclusion criteria: adult patients with indication for cholecystectomy. Exclusion criteria: patients under the age of 18 years old, pregnant women, patients with chronic diseases which require pain relievers (rheumatoid arthritis, oncologic diseases, etc.), previous surgery and patients who refuse to participate in the trial. The same insufflator was used with constant flow (20 l/m max) and the same laparoscopic device. Veress needle was used for pneumoperitoneum in all cases. Trocars were positioned using the American technique. Omalgia was assessed 12hs. after surgery. Results: The trial included 120 patients, who had undergone scheduled laparoscopic cholecystectomies. None of the patients required conversion to conventional surgery. With a mean age of 51 years old, ranging from 16 and 82 years of age, the incidence of omalgia was 40% for the group with 10 of insufflation pressure vs. 60% for the group with 12 mmHg of insufflation pressure, P=0.006. The incidence of shoulder pain was not different according to sex û20% women vs. 25% men (p=0.657)û nor for age, co-morbidity, fitness and/or surgeon...(AU)

[Primary anal tuberculous fissure]. / Fisura anal tuberculosa primaria.

The anal tuberculous (TBC) fissure is infrequent. For this reason diagnosis is difficult. A case of a female adult patient with anal TBC fissure that consults for bleeding and perianal pain is presented. The perianal tuberculosis is a rare manifestation of the general disease. A routine biopsy must be performed, with the corresponding histopathologic study. A specific origin should be suspected when an anal chronic fissure, painful and bleeding, without response to the habitual treatment, is found. The primary TBC fissure can be cured with the administration of three drugs during 3 to 4 months.

[Gastro-duodenal trichobezoars: a rare cause of obstruction of the gastrointestinal tract]. / Tricobezoares gastroduodenales: una causa poco frecuente de obstrucción del tracto de salida.

BACKGROUND: Trichobezoars represent 55% of human bezoars. Patients are women in 90% of cases and have some psychiatric disorder in 40%. OBJECTIVE: To study the clinical features, diagnostic methodology and treatment in patients with trichobezoars. DESIGN: Retrospective analysis of clinical records and case report. METHOD: Four patients were included between January 2000 and March 2004, 3 women and 1 man, with a mean age of 32.3 years (range 22 to 73 years). RESULTS: All patients had an epigastric mass, dyspepsia, vomiting, and weight loss of 5 to 25 kg, without pain. Three patients underwent barium studies, and all of them ultrasonography, computerized tomography and upper gastrointestinal endoscopy. All of them received endoscopic procedures without treatment success. Any patient referred trichophagy and all of them had psychiatric disorders. The surgical treatment was gastrotomy and removal of the bezoar. The average weight was 1,100 g (range 700 to 1,500 g). CONCLUSIONS: The trichobezoar is a rare cause of obstruction of the gastrointestinal tract. The diagnosis should be suspected with the clinical and barium study findings, and confirmed by computerized tomography and endoscopy. Surgery is the treatment of choice. However, other treatments have been described, such as endoscopic fragmentation, extracorporeal lithotripsy and laparoscopic extraction.