[Persistent elevation of Ca 19-9 and an unexpected finding. A case report]. / Elevación persistente de Ca 19-9 y un hallazgo inesperado. Reporte de un caso.

BACKGROUND: Tumour markers are substances produced by the tumour itself, or by the host in response to a tumour. These markers could be measured either in the blood or in body secretions. One of the most common tumour markers used in gastrointestinal diseases is Ca 19-9. It is the marker most used for pancreatic cancer, but can be elevated in many benign processes. Thus, it is not a specific marker. CLINICAL CASE: The case is presented of a male patient with 4 years of moderate abdominal pain, weight loss, and persistent elevation of Ca 19-9. After an extensive work-up, renal and hepatic cysts were found, as well as steatosis and, apparently, a gallbladder polyp. With these findings and the persistent elevation of Ca 19-9, it was decided to operate the patient. An exploratory laparoscopy was performed showing multiple, yellowish nodular lesions all over the hepatic surface suggestive of metastases, as well as simple hepatic cysts. Pathology reported biliary hamartomas, steatosis, and chronic cholecystitis. After 2years of follow up, although there is no evidence of malignant neoplasia, there is still an elevation of Ca 19-9. CONCLUSION: The persistent elevation of Ca 19-9 is probably due to the presence of multiple benign diseases such as steatosis, urolithiasis, hepatic and renal cysts, and cholecystitis. An algorithm is needed for healthy patients with elevated levels of Ca 19-9 marker, in order to lower costs, avoid misdiagnoses, and improve management.

[Obscure gastrointestinal bleeding due to gastrointestinal stromal tumors]. / Hemorragia gastrointestinal de origen oscuro por tumores de estroma gastrointestinal.

BACKGROUND: The gastrointestinal stromal tumours (GIST) are the most common soft tissue sarcomas of the digestive tract. They are usually found in the stomach (60-70%) and small intestine (25-30%) and, less commonly, in the oesophagus, mesentery, colon, or rectum. The symptoms present at diagnosis are, gastrointestinal bleeding, abdominal pain, abdominal mass, or intestinal obstruction. The type of symptomatology will depend on the location and size of the tumour. The definitive diagnosis is histopathological, with 95% of the tumours being positive for CD117. CLINICAL CASES: This is an observational and descriptive study of 5cases of small intestinal GIST that presented with gastrointestinal bleeding as the main symptom. The period from the initial symptom to the diagnosis varied from 1 to 84 months. The endoscopy was inconclusive in all of the patients, and the diagnosis was made using computed tomography and angiography. Treatment included resection in all patients. The histopathological results are also described. CONCLUSION: GIST can have multiple clinical pictures and unusual symptoms, such as obscure gastrointestinal bleeding. The use of computed tomography and angiography has shown to be an important tool in the diagnosis with patients with small intestine GISTs.

[Choledochal cyst during pregnancy. Report of 3 cases and a literature review]. / Quiste de colédoco y embarazo. Reporte de 3 casos y revisión de la bibliografía.

BACKGROUND: Choledochal cysts are rare. They usually present during childhood in women, but it can also be seen during pregnancy. Clinical signs and symptoms are obscured during this time, thus it can complicate the diagnosis and represent a life threatening complication for both the mother and the child. OBJECTIVE: To communicate the case of 3 pregnant patients with choledochal cyst. CLINICAL CASES: Three pregnant women in which choledochal cyst were diagnosed. Two developed signs of cholangitis. The first one underwent a hepatic-jejunostomy, but had an abortion and died on postoperative day 10. The second one had a preterm caesarean operation due to foetal distress and underwent a hepatic-jejunostomy 4 weeks later; during her recovery she had a gastric perforation and died of septic complications. The third one did not develop cholangitis or jaundice. She had an uneventful pregnancy and had a hepatic-jejunostomy 4 weeks later with good results. CONCLUSIONS: Management of choledochal cysts during pregnancy is related to the presence of cholangitis. When they do not respond to medical treatment, decompression of the biliary tree is indicated. Definitive treatment should be performed after resolution of the pregnancy.

[Appendiceal mucocele and gangrenous cholecystitis]. / Mucocele apendicular y colecistitis aguda gangrenada.

OBJECTIVE: We present a case report of appendiceal mucocele and gangrenous cholecystitis. SETTING: Hospital de Especialidades, Centro Médico Nacional Siglo XXI, México, D.F. CLINICAL CASE: An 80-year-old man was admitted to the hospital with diagnosis of acute cholecystitis and abdominal tumor under study, with complaints of abdominal pain for 10 days located in the right upper quadrant, without fever or significant weight loss. Laboratory analyses revealed moderate leucocytosis. CT of the abdomen revealed thickening of the gallbladder wall and acute local inflammation, as well as the presence of abdominal tumor in the right lower quadrant. The patient was surgically explored with the following findings: gangrenous cholecystitis and appendiceal tumor of 20 cm length. Cholecystectomy and appendectomy was performed. The postoperative period was normal. The final histological report was appendiceal mucocele and the patient was discharged after 5 days. The patient is currently without complaints at 5 months postoperatively.

[Gallstone ileus and cholecystoduodenal fistula. Case report]. / Ileo biliar y fístula colecistoduodenal. Informe de un caso.

OBJECTIVE: We report on a patient with gallstone ileus and cholecystoduodenal fistula at the Hospital de Especialidades, Centro Medico Nacional Siglo XXI (IMSS) Mexico City, Mexico. CLINICAL CASE: A 54-year-old male patient was admitted to the hospital with a diagnosis of acute cholecystitis. He had undergone an appendectomy at 34 years of age. There was no history of biliary disease. He was afebrile, with moderate abdominal distention and right upper quadrant pain, Murphy (+). His white blood cell count was 8,900/mm(3) with 40% bands. His liver function tests, amylase and lipase, were all within normal limits. Ultrasound revealed edema and thickening of the gallbladder wall with calculi. He underwent exploratory surgery, which provided the following findings: sclerotrophic gallbladder with intense surrounding inflammation. We therefore decided to perform a cholecystostomy. Two days postoperatively the patient presented abdominal distention and vomiting as well as the presence of intestinal material through the cholecystostomy catheter. Plain abdominal film showed the bowel to be dilated and an aberrantly located gallstone. Cholecystography was performed and showed a cholecystoduodenal fistula. Computed tomography was carried out and disclosed the bowel to be slightly dilated and with an intraluminal gallstone. A laparotomy with enterolithotomy was performed. Sized of the gallstone found was approximately 3 cm. Presently the patient is asymptomatic.

[Biliary ascariasis. Case report and review of the literature]. / Ascariasis biliar. Reporte de un caso y revisión en la literatura.

BACKGROUND: Ascaris lumbricoides is the most common nematode found in the human gastrointestinal tract with a greater prevalence found in developing tropical and subtropical countries. Most cases of ascariasis follow a benign course. In some cases the adult parasite can invade the biliary or pancreatic ducts and cause obstruction with development of cholecystitis, cholangitis, pancreatitis, and hepatic abscesses. We report a case of a patient with biliary ascariasis. CLINICAL CASE: A 40-year-old woman, born and residing in San Cristobal de las Casas, Chiapas, was admitted with right upper quadrant pain of 2-week duration. Pain was accompanied by nausea, vomiting and fever. Exploration revealed pain upon deep palpation of right hypochondria. Laboratory examinations demonstrated elevation of alkaline phosphatase without jaundice, leukocyte count of 14,300 and ultrasonography with ascaris within the gallbladder and intra- and extrahepatic ducts without evidence of dilatation. Medical treatment with mebendazol was begun orally; nevertheless, on the second day the patient reported an increase of the right hypochondria pain, vomiting and fever of 38 degrees C. Surgical treatment was decided upon. An open cholecystectomy was performed without evidence of parasites within the gallbladder. Expansion of the extrahepatic bile ducts was observed and a formal biliary exploration was carried out with extraction of 19 ascarids and colocalization of choledocostomy T-tube. At the third postoperative day, a T-tube cholangiography was done, showing residual ascarids in the biliary ducts that were resolved with a retrograde endoscopic cholangiopancreatography. The patient's evolution was without complications or fever and with adequate oral feeding posterior to biliary instrumentation. CONCLUSIONS: In obstructive biliary pathology, biliary ascariasis is a diagnosis that needs to be explored in our country. Knowledge of clinical symptoms, complications, and diagnostic and therapeutic options are of paramount importance for all health professionals in our country.

Mucocele apendicular y colecistitis aguda gangrenada / Appendiceal mucocele and gangrenous cholecystitis

Objetivo: descripción de un caso de mucocele apendicular y colecistitis aguda gangrenada, atendido en el Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS. Caso clínico: hombre de 80 años de edad que ingresó al hospital con diagnóstico de colecistitis aguda y tumor abdominal de etiología desconocida, dolor abdominal de 10 días de evolución localizado en hipocondrio derecho, sin fiebre ni pérdida importante de peso. Los exámenes de laboratorio mostraron únicamente leucocitosis moderada. La tomografía computarizada abdominal mostró vesícula biliar con paredes engrosadas y datos de agudización, así como tumor abdominal en fosa iliaca derecha. Se exploró quirúrgicamente con los siguientes hallazgos: colecistitis aguda supurada y tumoración apendicular de 20 cm de longitud, sin datos de malignidad. Se realizó colecistectomía y apendicectomía. El periodo posoperatorio transcurrió sin incidentes. El diagnóstico histopatológico fue de mucocele apendicular no roto. El paciente fue dado de alta a los cinco días. Pasados cinco meses de la intervención, se encontraba asintomático.

OBJECTIVE: We present a case report of appendiceal mucocele and gangrenous cholecystitis. SETTING: Hospital de Especialidades, Centro Médico Nacional Siglo XXI, México, D.F. CLINICAL CASE: An 80-year-old man was admitted to the hospital with diagnosis of acute cholecystitis and abdominal tumor under study, with complaints of abdominal pain for 10 days located in the right upper quadrant, without fever or significant weight loss. Laboratory analyses revealed moderate leucocytosis. CT of the abdomen revealed thickening of the gallbladder wall and acute local inflammation, as well as the presence of abdominal tumor in the right lower quadrant. The patient was surgically explored with the following findings: gangrenous cholecystitis and appendiceal tumor of 20 cm length. Cholecystectomy and appendectomy was performed. The postoperative period was normal. The final histological report was appendiceal mucocele and the patient was discharged after 5 days. The patient is currently without complaints at 5 months postoperatively.

[Intussusception in adults]. / Invaginación intestinal en adultos.

Intestinal intussusception in adults is a very rare entity whose etiology differs greatly from its pediatric counterparts. Three adult patients with intestinal intussusception presented with intestinal obstruction and required surgery for its resolution. In each case a pathologic cause was found. They had intestinal polyps, two benign (lipoma and hamartomatous polyps) and one malignant (metastasis). Intestinal intussusception in adults usually has a pathologic cause. About half have a malignant etiology. Intestinal resection without reduction of the intussusception is the preferred surgical procedure.

[Management of the abdominal wall in sepsis. Comparison of two techniques]. / Manejo de la pared abdominal en sepsis. Comparación entre dos técnicas.

OBJECTIVE: To compare two techniques of open abdomen management in patients with abdominal sepsis. INTRODUCTION: Some patients with abdominal sepsis will require open abdomen management to avoid abdomen compartment syndrome. We compare use of the Bogota bag with a technique developed at our Institution with a subcutaneous polyethylene bag. METHODS: Thirty nine consecutive patients with abdominal sepsis who were managed with open abdomen. RESULTS: Twenty one patients with Bogota bag and 18 patients with subcutaneous polyethylene bag. Patients with Bogota bag had more report surgery intrabdominal complications compared with patients with subcutaneous polyethylene bag (p = 0.04, p = 0.037, respectively). Mortality was the same. CONCLUSIONS: Use of subcutaneous polyethylene bag in patient with abdominal sepsis and open abdomen appears safer when compared with Bogota bag.

[Sclerosing encapsulated peritonitis. Diagnostic and therapeutic challenge for the general surgeon]. / Peritonitis esclerosante encapsulante. Reto diagnóstico y terapéutico para el cirujano general.

Intestinal obstruction is one of the most frequently abdominal problems that concern general surgeons. One of the infrequent causes of mechanical obstruction is sclerosing encapsulating peritonitis (SEP); this entity causes intense fibrosis of the components in the peritoneal layer, resulting in adhesion of abdominal organs. SEP can be primary or secondary; both are a type of peritoneal fibrosclerosis that causes intestinal obstruction with difficult resolution and a great number of complications. In terms of frequency and etiology, there are few data, and the problem is considerated a multifactorial disease with association to neoplasms, toxics, drugs, and idiopathic form. This article presents three cases of sclerosing encapsulating peritonitis and the possible factors that play an important role in the development of this infrequent entity.

[Intraabdominal hypertension and abdominal compartment syndrome in patients with acute pancreatitis]. / Hipertensión intraabdominal y síndrome compartamental abdominal en pacientes con pancreatitis aguda.

BACKGROUND: Intra-abdominal pressure rises in some circumstances and can cause abdominal compartment syndrome. Severe acute pancreatitis frequently causes abdominal compartment syndrome. OBJECTIVE: Our objective was to identify the relationship between severity of pancreatitis and abdominal pressure. MATERIAL AND METHODS: From September 2001 to September 2002, all patients with acute severe pancreatitis were included in the study; exclusion was effected with history of abdominal surgery for pancreatitis or ventral hernias. In all patients, we carried out laboratory tests to establish ranson criteria, Apache II score, and indirect measurement of abdominal pressure. Lineal regression and chi-square test were done. RESULTS: A total of 25 patients was included, 10 men and 15 women, average age 49.4 years, 11 with mild pancreatitis and 14 with severe acute pancreatitis. Abdominal pressure was 2 to 19 cm H2O. On statistic analysis, there was strong positive correlation between Apache II score and IAP and 0.781 of correlation coefficient and 99.5% confidence interval.

Tratamiento quirúrgico de la enfermedad por reflujo gastroesofágico / Surgical treatment for gastroesophageal reflux disease

Objetivo: Evaluar el tratamiento quirúrgico laparoscópico de la enfermedad por reflujo gastroesofágico, la efectividad y las complicaciones, por un mismo equipo quirúrgico. Diseño: Estudio retrospectivo y longitudinal. Material y método: Se analizaron los resultados de 129 pacientes con enfermedad por reflujo gastroesofágico operados mediante laparoscopia entre enero de 1992 y junio del 2001. Resultados: Fueron operados 89 hombres y 48 mujeres, con edad media de 41.5 años. En el 100 por ciento se llevó a cabo panendoscopia, en 78 por ciento manometrías y en 21 por ciento pHmetrías. Se efectuaron cuatro funduplicaturas a 360º y 125 funduplicaturas posteriores a 270º. El tiempo de seguimiento fue de uno a 12 meses. Se presentaron complicaciones mayores en dos pacientes y menores en 17. El tiempo quirúrgico promedio fue de 71 minutos. Sólo hubo una conversión. El tiempo promedio de estancia hospitalaria fue de 31.30 horas. Conclusión: El tratamiento quirúrgico por vía laparoscópica es seguro, eficiente y ofrece resultados a largo plazo sin modificaciones en la forma de vida.

Perforación esofágica por dilatación con balón en un paciente con acalasia / Esophagic perforation due to a pneumatic dilatation in a patient with achalasia

Objetivo: presentar un caso de perforación esofágica por dilataciones con balón neumático en un paciente con acalasia. Antecedentes: la acalasia del esófago es una alteración motora primaria cuya etiología permanece desconocida. Se caracteriza por la disminución, ausencia de peristaltismo o ambas en el cuerpo del esófago y por falta de relajación del esfínter esofágico inferior como respuesta a la deglución. Debido al carácter primario de esta enfermedad, su fisiopatología y las alteraciones funcionales que produce, los tratamientos en todas sus modalidades son paliativos ya sea farmacológico, con dilatación neumática o con cirugía, cuando se produce una lesión esofágica ésta debe ser sospechada y tratada de manera inmediata, porque el retraso en el diagnóstico influye de manera directa en el pronóstico del paciente. Método: se presenta un caso de perforación esofágica por dilataciones con balón en un paciente con acalasia. Conclusiones: una paliación útil de los síntomas de la acalasia es la dilatación con balón neumático, ésta conlleva cierto riesgo de perforación, por lo que hay que sospecharla en todo paciente que se somete a dilatación esofágica y su condición clínica se ve alterada, el éxito del tratamiento quirúrgico de la perforación esofágica y del control de la sepsis depende directamente de las condiciones previas del paciente y del tiempo transcurrido entre la lesión y la cirugía.

Una opción más en la repación de la hernia inguinal / Another alternative for inguinal hernia repair

Objetivo: Brindar una opción más para la reparación de las hernias inguinales. Material y métodos: De abril de 1986 a abril de 1996 se realizaron 312 hernioplastias con colocación de material sintético; 271 fueron reparaciones primarias y 41 fueron reparaciones de hernias recidivantes. Todas eran hernias directas, 271 directas y 41 recividantes, clasificadas por el método de Gilbert. Se realizó abordaje anterior, utilizando el ligamento de Cooper y el tracto iliopúbico, formando la malla de polipropileno parte de la plastia misma, quedando doblada sobre ella misma (en un doblez) y no como parche o empastamiento sobre el defecto herniario. Resultados: Se presentó recidiva en 0.32 por ciento (un caso) en un paciente con hernia recidivante por tercera ocasión, a los 28 meses de su cirugía, coincidiendo con una resección transuretral de próstata. Las complicaciones se limitaron a ocho seromas y nueve hematomas subdérmicos (5.29 por ciento). El promedio de estancia hospitalaria fue de 28 horas. El seguimiento máximo de los pacientes fue de cinco años, con un promedio de cuatro años. Conclusiones: Creemos firmemente que esta es una excelente alternativa y este reporte así lo demuestra. Sin embargo, sólo a través del tiempo podremos contestar la pregunta de ¿cuál es el método ideal de reparación en una hernia inguinal? Es indispensable el uso de material sintético (polipropileno) en la hernioplastia inguinal para evitar recidivas tardías.

Pancreatoduodenectomía en hemorragia de tubo digestivo. Reporte de un caso / Pancreaticoduodenectomy in digestive tract hemorrhage. Report of a case

Objetivo: describir la presentación clínica y el tratamiento de un paciente con neoplasia pancreática neuroendocrina y hemorragia de tubo digestivo. Antecedentes: los tumores neuroendocrinos del páncreas son neoplasias relativamente raras; cuando no son funcionantes el cuadro clínico es inespecífico y se manifiestan hasta que la neoplasia ha adquirido grandes dimensiones. La hemorragia masiva de tubo digestivo alto es una manifestación clínica poco frecuente de este tipo de tumores. Método: se presenta un caso en el cual se requiere tratar una hemorragia masiva de tubo digestivo alto con pancreatoduodenectomía de urgencia por una neoplasia ulcerada de la cabeza del páncreas. Conclusión: la pancreatoduodenectomía es sin duda el procedimiento de elección para control de la hemorragia masiva duodenal en presencia de una neoplasia neuroendocrina del páncreas ulcerada.