Atypical umbilical endometriosis: Microscopic and immunohistochemical characterization / Endometriosis atípica umbilical. Caracterización microscópica e inmunohistoquímica

Introduction: Atypical endometriosis is considered a precursor lesion to cancer associated with endometriosis. Two types of atypical endometriosis have been proposed: an architectural type with a higher risk of malignancy and a cytological type with a lower potential for malignancy. Main symptoms and/or clinical findings: A 37-year-old Caucasian woman presented with umbilical bleeding coinciding with menstruation. On physical examination, two small, bluish lesions were observed in the umbilical scar. Primary diagnosis: This clinical case is of interest because it describes a lesion of atypical architectural endometriosis located in the navel. Therapeutic interventions and results: The microscopic and immunohistochemical characteristics of the lesion were examined. The presence of nuclear stratification, hyperchromatism, and pleomorphism were observed as microscopic qualities. In terms of the immunohistochemical panel, the degree of cell proliferation was analyzed using Ki 67, BAF250a was used as the surrogate marker of ARID 1A, inflammation was assessed through COX, and estrogen and progesterone receptors were examined. The results showed increased cellular activity, the presence of inflammation, and no mutation of the ARID1a gene, with moderate cell proliferation. Conclusion: Umbilical endometriosis is rare, and while malignancy is infrequent, it is possible. For this reason, a complete anatomopathological study including an immunohistochemical panel should be performed to diagnose atypical endometriosis.(AU)

Introducción: La endometriosis atípica está considerada como una lesión precursora de cáncer asociado a endometriosis. Se han propuesto 2 tipos de endometriosis atípica, una arquitectural con mayor riesgo de malignización y otra citológica cuyo potencial de malignización es menor. Principales síntomas y/o hallazgos clínicos: Una mujer de 37 años caucásica consulta por sangrado catamenial umbilical. A la exploración física se observan 2 pequeñas lesiones umbilicales azuladas. Diagnóstico principal: Este caso clínico es interesante porque se describe una lesión de endometriosis atípica arquitectural localizada en el ombligo. Intervenciones terapéuticas y resultados: Se ha descrito sus características microscópicas e inmunohistoquímicas para caracterizarla. La presencia de estratificación nuclear, hipercromatismo y pleomorfismo como cualidades microscópicas y en cuanto al panel inmunohistoquímico se ha analizado el grado de proliferación celular mediante el Ki-67, BAF250a como el marcador subrogado del ARID1A, el grado de inflamación mediante COX y los receptores estrogénicos y gestagénicos. Los resultados demuestran que tiene una actividad celular aumentada, presencia de inflamación y no mutación del gen ARID1A con moderación proliferación celular. Conclusión: La endometriosis umbilical es poco frecuente y su malignización, aunque rara es posible. Por esta razón, se debería realizar un estudio anatomopatológico completo que incluya un panel inmunohistoquímico en aras de diagnosticar endometriosis atípica.(AU)

Onfaloplastia: técnica Y/V / Omphaloplasty: Y/V technique

Introdução: A onfaloplastia é um momento crucial durante a cirurgia de abdominoplastia. Apesar de ser considerada uma etapa de grande importância nos dias de hoje, a onfaloplastia não foi sempre utilizada nas abdominoplastias, sendo o umbigo, algumas vezes, descartado junto ao retalho gorduroso. Com a finalidade de preservar a cicatriz umbilical, várias técnicas foram utilizadas e, com o tempo, vêm sofrendo modificações que possibilitam um resultado cada vez mais natural. Método: A técnica "Y"/"V" proposta consiste em modelar o coto umbilical de modo que este encaixe perfeitamente no mesmo local onde havia a cicatriz umbilical. A ilha umbilical, após ser modelada, é suturada, resultando em uma imagem de "Y"/"V", razão pela qual a técnica recebe este nome. Resultados: Durante o estudo, foi evidenciado um número baixo de complicações (11,34%) ao analisar o pós-operatório. Deiscência de sutura, estenose umbilical, alterações crômicas na cicatriz e queloide foram as complicações observadas, sendo corrigidas cirurgicamente seis meses após a cirurgia. Conclusão: A técnica proposta demonstra simples execução, com baixos índices de complicações e aspecto mais natural da cicatriz do neoumbigo. Portanto, tornam-se cada vez mais necessários estudos que a utilizem para comprovar sua eficácia perante às demais técnicas utilizadas atualmente.

Introduction: Omphaloplasty is a crucial procedure during abdominoplasty surgery. Although it is currently considered an important step, omphaloplasty was not always performed during abdominoplasties, and the umbilicus was sometimes discarded together with the fat flap. Various techniques were used to preserve the umbilicus and underwent modifications with time to allow for an increasingly natural result. Method: The proposed "Y"/"V" technique consists of modeling the umbilical stump to perfectly fit in the same place where the umbilicus was located. The umbilical island, after being modeled, is sutured, resulting in a "Y"/ "V" image, which gives rise to the name. Results: A low number of complications (11.34%) were observed when analyzing the postoperative follow-up data. Suture dehiscence, umbilical stenosis, color alterations in the scar, and keloid scars were the complications observed, which were surgically corrected six months postoperatively. Conclusion: The proposed technique is simple to implement, with low rates of complications and results in a more natural aspect of the neoumbilicus scar. Further studies are required to prove its effectiveness in comparison to the other techniques that are currently in use.

Risk Factors for Transumbilical Wound Complications in Laparoscopic Gastric and Colorectal Surgery.

AIM: To investigate the risk factors of transumbilical incision for organ removal in laparoscopic surgery. PATIENTS AND METHODS: We enrolled 643 consecutive patients undergoing laparoscopic surgery from 2010 to 2013. Superficial surgical site infection (SSI) and transumbilical port site hernia were recorded. RESULTS: The participants underwent gastric (n=253) and colorectal (n=390) resections. SSI was observed in 17 cases (colorectal in 15; gastric in two) (2.64%) with colorectal resection having a high rate of SSI [odds ratio (OR)=5.020; p=0.022]. Hernia occurred in 23 cases (colorectal in 22; gastric in one) (3.53%), with a significantly higher rate for colorectal resection (OR=13.052; p<0.001). Female (OR=5.410; p=0.021) and history of diabetes mellitus (OR=4.437; p=0.009) contributed to the risk for developing a hernia. CONCLUSION: Especially in relation to hernia, being female and having diabetes mellitus were considered independent risk factors.

Avaliação estética da cicatriz umbilical em duas técnicas de onfaloplastia / Aesthetic evaluation of two omphaloplasty techniques

Introdução: O tratamento da cicatriz umbilical é um tempo muito importante na plástica abdominal. Existem várias técnicas descritas de onfaloplastia na literatura. Objetivo: Este trabalho tem com objetivo comparar o resultado estético de onfaloplastias com as técnicas em estrela e losango. Método: Foram avaliados os resultados de 20 pacientes, por meio de pontuação, utilizando cinco critérios: formato, localização, cicatriz, tamanho e profundidade. Resultado: As pacientes apresentaram somatória significativamente maior de pontos no critério que avaliou o formato da onfaloplastia, sendo utilizada a técnica em estrela 15,8± 2,05, quando comparada com a técnica de onfaloplastia em losango 12,6± 3,65 com p=0,03. Nos demais critérios de localização, tamanho, profundidade e cicatriz não houve diferenças significantes. Conclusão: O estudo demonstrou que a técnica em estrela apresentou melhores resultados estéticos no critério de formato do que a técnica em losango.

Introduction: The treatment of umbilical scarring is important in abdominoplasty, and many omphaloplasty techniques are described in the literature. Objetive: The objective of this work is to compare the aesthetic result of omphaloplasty with the star technique and the diamond technique. Method: Twenty patients were evaluated through scoring, by using five criteria: shape, location, scar, size, and depth. Result: The patients showed significantly higher scores when evaluating the shape criterion during an omphaloplasty; the star technique scored, on average, 15.8 ± 2.05, whereas the diamond technique scored 12.6 ± 3.65 (p = 0.03). No significant difference was found in all other criteria (location, size, depth, and scar). Conclusion: This study demonstrates that the star technique produces better aesthetic results than the diamond technique.

Neonatal skin and chlorhexidine: a burning experience.

PURPOSE: Despite the lack of safety data, chlorhexidine gluconate (CHG) is an antiseptic with broadspectrum coverage often used in neonatal intensive care units (NICUs). Adverse skin reactions, most commonly burns, have been reported after the use of CHG. Preserving skin integrity in preterm infants is vital in the prevention of sepsis, excessive water loss, hypothermia, and renal failure. DESIGN: This is a case report of two incidents of significant skin burning in extremely low birth weight (ELBW) infants who were treated with CHG for the purposes of umbilical cord sterilization prior to umbilical line placement. SAMPLE: This case report of burns associated with CHG in one infant weighing 610 g at birth and a second infant weighing 600 g at birth. RESULTS: CHG does have a strong association with causing skin burns in the ELBW population; however, wiping the solution off of the skin seems to reduce injury.

Vitello-intestinal duct injury after transabdominal preperitoneal inguinal hernia repair.

A 71-year-old patient underwent a transabdominal preperitoneal right inguinal hernia repair and presented to the emergency department 48 hours postoperatively with nonspecific abdominal and chest pain and was diagnosed an abdominal abscess at the umbilicus by computed tomography. Laparotomy showed a vitello-intestinal duct injury caused by the umbilical trocar at his previous laparoscopic surgery. We will discuss this rare complication and how to avoid it in future practice.

Umbilical scar autonomization: a safe technique for secondary abdominoplasties / Autonomização da cicatriz umbilical: técnica segura para abdominoplastias secundárias

BACKGROUND: In lipominiabdominoplasty and mid-abdominoplasty procedures, the umbilicus is usually undermined from its aponeurotic fixation; this modifies its normal vascular pattern. In patients undergoing these procedures and candidates for a secondary classic abdominoplasty, trophic changes, including necrosis, may occur in the umbilical scar. To avoid trophic complications in the neo-umbilicus, autonomization of the umbilical scar was carried out. METHODS: Three candidates for a secondary classic abdominoplasty underwent the umbilicus autonomization process in the private clinic of the corresponding author. One incision, 1 cm from the umbilical scar, was performed from the skin to the aponeurotic plane on each side, with an interval of 15 days between the two surgical incisions. After the second incision, the patient waited for a further 15 days. Thus, the whole process took 30 days before classic abdominoplasty was performed. RESULTS: No trophic alterations or necrosis in the umbilical scar were observed in these cases. CONCLUSIONS: The aesthetic results were satisfactory, indicating the effectiveness of this method.

INTRODUÇÃO: Nos procedimentos de lipominiabdominoplastia e midiabdominoplastia, usualmente, o umbigo é destacado de sua fixação aponeurótica, o que modifica o padrão vascular do umbigo. Em pacientes submetidos a esses procedimentos e candidatos a abdominoplastia clássica secundária, podem ocorrer alterações tróficas da cicatriz umbilical e, até mesmo, necroses. Utilizou-se a manobra de autonomização da cicatriz umbilical para evitar complicações tróficas do neoumbigo. MÉTODO: Foram submetidas ao processo de autonomização da cicatriz umbilical 3 pacientes candidatas a abdominoplastia clássica secundária, na clínica privada do autor principal. A técnica compreende uma incisão a 1 cm da cicatriz umbilical, desde a pele até o plano aponeurótico, de cada lado, com intervalo de 15 dias entre cada etapa, no total de dois tempos cirúrgicos. O processo como um todo leva 30 dias, antes da abdominoplastia clássica. RESULTADOS: Não foram observadas alterações tróficas ou necroses da cicatriz umbilical nos casos submetidos ao processo de autonomização. CONCLUSÕES: Os resultados estéticos foram satisfatórios, o que atestou a efetividade do método.

Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy.

OBJECTIVE: To report the novel technique of periumbilical ultrasound-guided saline infusion (PUGSI). DESIGN: Prospective study of two noninvasive diagnostic tests to detect obliterating subumbilical adhesions. SETTING: Tertiary care center. PATIENT(S): One hundred fifty patients were included in the study. Patients without risk factors for adhesions were used as a control group (n = 38), whereas the study group had risk factors for intra-abdominal adhesions (n = 112). INTERVENTION(S): Preoperative examination with the visceral slide and the PUGSI. MAIN OUTCOME MEASURE(S): The presence of obliterating subumbilical adhesions in the high-risk patient and the ability of the PUGSI to detect them preoperatively. RESULT(S): There were no obliterating umbilical adhesions in the control group. The prevalence of obliterating umbilical adhesions in the risk group was 3.6%. The visceral slide test had an accuracy of 96.4%, a sensitivity of 50%, and a specificity of 98.1%, with a negative predictive value of 98.1% and a positive predictive value of 50%. The PUGSI test was able to detect all cases of obliterating subumbilical adhesions, demonstrating sensitivity and specificity of 100%. CONCLUSION(S): The PUGSI test has excellent negative and positive predictive values and is useful in determining patients who have obliterating subumbilical adhesions. Use of both tests preoperatively appears to be helpful in identifying patients at risk for visceral injury during laparoscopic surgery.

Umbilical CSF fistula: a rare complication of ventriculoperitoneal shunt.

An umbilical CSF fistula following a ventriculoperitoneal shunt is an extremely rare complication. We report a 28-year-old man who presented with leak of clear fluid from the umbilicus, one month after a ventriculo-peritoneal shunt revision. Shuntogram revealed communication between umbilicus and abdominal end of the catheter. He was managed successfully with shunt exteriorization, antimeningitic treatment, and later shunt re-insertion.

Umbilical perforation: an unusual complication of a ventriculoperitoneal shunt.

INTRODUCTION: Ventriculoperitoneal shunt operations are the most common pediatric neurosurgical procedures in the treatment of hydrocephalus. However, ventricular shunting is frequently associated with a wide variety of complications. Umbilical perforation is an extremely rare complication of ventriculoperitoneal shunts. CASE REPORT: We present an infant with umbilical abscess, meningitis, and umbilical perforation of the distal end of the ventriculoperitoneal shunt, which was placed for congenital hydrocephalus.

Reconstrução de umbigo após ressecção de foco de endometriose / Umbilicus reconstruction after endometriosis scar

Várias técnicas têm sido utilizadas para reconstruir a cicatriz umbilical, mas nenhuma tem mostrado ser a ideal para todos os casos. Os autores apresen- tam um caso de reconstrução imediata de umbigo, utilizando uma técnica de simples execução, realizada após ressecção de foco de endometriose.

Various techniques have been used to reconstruct umbilical scar, however none have appeared to be the ideal for all cases. The authors present a case of imediat reconstruction of umbilicus making use of an simple technique wich was done after resection if umbilical endometriosis.

Eficacia de una aplicación frente a tres de merbromina en el tiempo de caída del cordón / Efficacy of one versus three applications of merbromin in achieving umbilical cord detachment

Objetivo: comparar la eficacia de dos pautas de aplicación de la merbromina (una aplicación diaria frente a tres) en el tiempo de caída del cordón umbilical. Método: un total de 285 neonatos fueron asignados aleatoriamente a uno de los dos grupos de estudio. Se obtuvo información completa de 280 neonatos (145 en el grupo de tres aplicaciones y 135 en el grupo de una aplicación). Se recogieron las siguientes variables: tipo de parto, peso y apgar del recién nacido, días hasta la caída del cordón, efectos adversos, grado de dificultad de la cura del ombligo y preocupación de los padres. Resultados: en el grupo de tres aplicaciones de membromina diarias la caída del cordón se produjo a los 10,8 +/- 6,1 días, mientras que en el grupo de una aplicación fue a los 8,8 +/- 3,9 días (9<0,001). No se detectó ningún cado de onfalitis ni alergias. No se observaron diferencias significativas en la aparición de granulomas (4,1 por ciento en el grupo de tres aplicaciones y 3,7 por ciento en el de una aplicación ). Conclusiones: una única aplicación diaria de merbromina en el cuidado umbilical presenta un buen efecto curativo, menor tiempo de caída del cordón, menor coste y mayor seguridad para los padres (AU)

The spontaneous umbilical perforation of the distal end of ventriculoperitoneal shunt.

We present a case of umbilical perforation of the distal end of ventriculoperitoneal shunt as a rare complication of ventriculoperitoneal shunts including an umbilical abscess and an infection related with ventriculoperitoneal shunt. The ventriculoperitoneal catheter was removed, the umbilical abscess was drained and appropriate medication was employed for infection with successful outcome. Possible factors that might predispose to these complications of ventriculoperitoneal shunting are suggested.