carlos casimiro - Academia.edu (original) (raw)
Papers by carlos casimiro
HPB, 2019
In the logistic regression model, LNY and tumor size positively correlated with N1 stage. Conclus... more In the logistic regression model, LNY and tumor size positively correlated with N1 stage. Conclusion: SPE is associated with higher LNY in patients with PAC, which increases the likelihood of detecting positive lymph nodes and reduces the risk of understaging. These findings also indicate that ST is adequate.
An 80-year-old female patient, with obesity and arterial hypertension, was admitted to our emerge... more An 80-year-old female patient, with obesity and arterial hypertension, was admitted to our emergency department, for periumbilical pain and constipation in the last 6 days. She presented with abdominal distension and a large irreducible hernia in her right lower quadrant. She had an abdominal Computerized Tomography (CT) done that confirmed the clinical suspicion of a Spiegel hernia, containing colon and a large quantity of omentum (Figure 1). She underwent an urgent surgery (Figure 2): laparoplasty with a dual surface mesh, and was discharged home on the 4th post-operative day. She remains asymptomatic, with no hernia relapse. The diagnosis of this hernia requires a high suspicion index and the CT is the best imaging study for their characterization. The incarceration risk of this hernia is high. Thirty percent of these patients require an urgent surgery. Hence, surgery is recommended for all patients presenting with a Spiegel hernia.
International Journal of Surgery Case Reports, 2020
INTRODUCTION: Most abdominal cysts derive from the ovary. The range of differential diagnoses is ... more INTRODUCTION: Most abdominal cysts derive from the ovary. The range of differential diagnoses is wide. Unfortunately, imaging studies not always determine its origin. PRESENTATION OF CASE: The authors present the case of a 20-year-old female patient, admitted to the emergency department due to abdominal pain and distension, whose imaging studies revealed a gigantic abdominal cyst of unknown origin. She underwent an exploratory laparotomy that disclosed an ovarian cyst that was removed by a left adnexectomy. It weighed 10Kg and was 60 cm wide. The pathology report showed a mucinous cyst adenoma. DISCUSSION: Once a patient present with an abdominal cyst, one should always consider the extensive list of differential diagnoses. In premenopausal women, ovarian cysts are very frequent. Cysts may grow to considerable size. Our patient was symptomatic, malnourished and dehydrated. Neither ultrasonography nor computed tomography were able to define the origin of the cyst. Persistent ovarian cysts larger than 10 cm, particularly if symptomatic, should be considered for surgery. CONCLUSION: Progressive abdominal distension in premenopausal women should raise suspicion of an ovarian tumor, such as mucinous cystadenoma. These tumours are benign, but when their size is considerable, complications do arise and their surgical removal may be life threatening.
HPB, 2019
up on the pancreatic pathoanatomy. Most patients with such findings have inoperable conditions, h... more up on the pancreatic pathoanatomy. Most patients with such findings have inoperable conditions, however very rarely inflammatory pseudotumors can mimick their appearance and surgical exploration provides the necessary safety to conduct a cortisone therapy that would be detrimental otherwise.
Journal of Surgical Case Reports, 2019
Spontaneous posterior rectus sheath hernia is perhaps one of the rarest hernias described only in... more Spontaneous posterior rectus sheath hernia is perhaps one of the rarest hernias described only in a few published cases. We present the case of a small bowel herniation through the posterior rectus sheath in a woman without previous abdominal surgical history, resulting in acute small bowel obstruction who was successfully treated by laparoscopy. This is the first case report of this kind of hernia managed with laparoscopic technique. Although the laparoscopic approach is not considered standard treatment for strangulated hernias, in selected cases, it allows the identification and repair of the defect.
Case Reports in Surgery, 2019
Gastrointestinal stromal tumors (GIST) comprised 0,2% of all GI tumors. They are typically asympt... more Gastrointestinal stromal tumors (GIST) comprised 0,2% of all GI tumors. They are typically asymptomatic, but can manifest with nonspecific GI symptoms, GI bleeding, or intussusception. The authors report a case of a 55-year-old female patient with hematochezia and a palpable mass on the left lower quadrant. Ultrasound revealed possible intussusception. However, CT scan did not show any signs of lesions or intussusception. On reevaluation, the mass was no longer palpable. The patient had recurrent episodes of hematochezia with need of transfusional support. CT enterography revealed a 20-24 mm jejunoileal lesion. A laparotomy was undertaken with small bowel resection containing the lesion. Histological examination confirmed GIST. GIST presentation as transient intussusception and intermittent GI bleeding is rare. This case report emphasizes the rarity of jejunoileal GIST, its clinical details, diagnostic study, and treatment.
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](Journal of surgical case reports, 2018
The progresses made in minimally invasive surgery, make it not only possible to perform isolated ... more The progresses made in minimally invasive surgery, make it not only possible to perform isolated cholecystectomy, but also to provide a totally laparoscopic treatment of common bile duct lithiasis. In this approach, the use of choledochoscopy is indispensable for diagnostic and therapeutic success. This study describes the use of a disposable endoscope for choledochoscopy in the laparoscopic treatment of choledocholithiasis. We have analyzed the use of the Ambu aScope 3 disposable endoscope, normally used for bronchoscopy, in nine consecutive patients needing choledochoscopy in our Hospital. The patient average age was 78 years. Total clearance of the bile duct was obtained in seven patients. Bile duct vacuity was not obtained in two patients, but this is not attributed to equipment failure. There was one case of hemoperitoneum not related to equipment usage. This device is easy to use and looks promising for choledochoscopy in laparoscopic treatment of coledocholithiasis.
Journal of surgical case reports, 2018
Wilkie's syndrome, or superior mesenteric artery syndrome (SMAS), is a rare clinical entity c... more Wilkie's syndrome, or superior mesenteric artery syndrome (SMAS), is a rare clinical entity caused by compression of the third portion of the duodenum between the abdominal aorta and superior mesenteric artery, leading to duodenal obstruction and severe malnutrition. The authors report a case of a female patient with years of chronic intestinal obstruction with abdominal pain, vomits and weight loss. Contrast intestinal series showed dilation of stomach and duodenum. Abdominal computed tomography study revealed findings compatible with SMAS. After initial nutritional support, she was successfully treated by laparoscopic duodenojejunostomy. Surgical treatment of SMAS may be necessary in most cases with chronic symptoms or conservative treatment failure. A minimally invasive approach can be considered a safe surgical option with favourable outcomes. Clinical details, diagnostic studies and treatment are discussed.
Journal of Surgical Case Reports, 2020
Von Recklinghausen disease (neurofibromatosis type 1—NFT1) is a genetic disorder with autosomal d... more Von Recklinghausen disease (neurofibromatosis type 1—NFT1) is a genetic disorder with autosomal dominant inheritance pattern, caused by mutation of a tumour suppressor gene. Its main features include multiple cutaneous café-au-lait spots and neurofibromas. It is associated with an increased risk of developing neuroendocrine tumours, for instance, in the duodenum. The authors present a case of a 23-year-old male patient admitted to the emergency department due to persistent vomiting. Imaging and biopsy studies revealed an obstructive and large duodenal neuroendocrine tumour; hence the patient underwent a pancreaticoduodenectomy.
International journal of surgery case reports, 2018
Acute appendicitis is the main indication for surgery during pregnancy. Physiologic changes durin... more Acute appendicitis is the main indication for surgery during pregnancy. Physiologic changes during pregnancy and fear of using ionising radiation exams are some of the reasons to delayed diagnosis and consequently to higher morbidity and mortality rates for mother and fetus. We present the case of a 38-year-old woman that resorted to the emergency room on the 13th week of pregnancy with abdominal discomfort, nausea and vomiting that lasted for 7 days. She had been in the Obstetric Emergency Department 6 days prior with the same complaints. She had no fever and she was discharged home following normal obstetric ultrasound. On this second visit, after surgical consultation, septic shock with abdominal source was recognised and patient was taken for emergency exploratory laparotomy. Intraoperatively we found generalised purulent peritonitis secondary to perforated acute appendicitis. Appendectomy, thorough abdominal washing and laparostomy were performed. Patient was admitted on the In...
Cureus, 2021
Non-islet cell tumor hypoglycemia is a rare paraneoplastic condition caused by an extra-pancreati... more Non-islet cell tumor hypoglycemia is a rare paraneoplastic condition caused by an extra-pancreatic tumor. We report a rare case of hypoglycemia caused by a relapsing pelvic solitary fibrous tumor associated with Big-IGF-2 production. A 72-year-old woman was admitted to our hospital because of loss of consciousness and hypoglycemia. She had a history of ovarian solitary fibrous tumor, which has relapsed. From investigation, serum levels of insulin and C-peptide were suppressed; IGF-1 was slightly reduced and IGF-2 was within the normal range, but the IGF-2: IGF-1 ratio was elevated, indicating the presence of Big-IGF-2 secreting non-islet cell tumor. Contrast-enhanced computed tomography (CT) showed a large pelvic mass. She was then submitted to surgical resection of the mass, which histologically proved to be a solitary fibrous tumor. Three months later, she remains asymptomatic. Non-islet cell tumor hypoglycemia should be considered in the differential diagnosis of patients presenting with tumors and recurrent hypoglycemia.
International Journal of Surgery Case Reports, 2019
INTRODUCTION: Boerhaave's syndrome is a life-threatening oesophageal perforation that carries a h... more INTRODUCTION: Boerhaave's syndrome is a life-threatening oesophageal perforation that carries a high mortality rate (20-50%). Diagnosis is difficult by its rarity and the absence of typical symptoms. Treatment of this condition usually requires surgical intervention. PRESENTATION OF CASE: We report the case of a 77-year-old man that resorted to the emergency room with dyspnoea and thoracic pain after vomiting. CT scan revealed pneumomediastinum, left collapse lung and loculated pleural effusion. A left intercostal chest tube was inserted with food drainage. Hence, Boerhaave's syndrome was suspected. Thoracotomy with mediastinum debridement, pleural drainage and oesophageal T-tube drainage was performed. Patient was admitted on the Intensive Care Unit with septic shock, with need for ventilatory support and vasopressor therapy. Two days later, a second look thoracotomy was done with definitive oesophageal repair and pleural patch. The post-operative course was complicated by pneumonia and stroke. Patient was discharged home on the 38th day and remains well at 3 month of follow-up. DISCUSSION: Delayed diagnosis and treatment are the principal causes of high mortality in Boerhaave's syndrome. The classic Mackler's triad (vomiting, lower thoracic pain and subcutaneous emphysema) is present in less then 50% of cases. A thoracic drainage may be useful to confirm diagnosis promptly. There is no standard treatment option. In this case report, the authors used a damage control approach to control sepsis, allowing for a delayed definitive oesophageal repair. CONCLUSION: Prompt diagnosis with thoracic drainage and a damage control treatment plan might lead to good prognosis for patients with this rare and potentially fatal condition.
American Journal of Case Reports
Rare disease Background: Wunderlich's syndrome, or spontaneous non-traumatic retroperitoneal hemo... more Rare disease Background: Wunderlich's syndrome, or spontaneous non-traumatic retroperitoneal hemorrhage, can be a life-threatening event. Renal angiomyolipoma is a rare benign tumor that can occur sporadically, or in association with tuberous sclerosis. A case of spontaneous retroperitoneal hemorrhage in a patient with tuberous sclerosis and bilateral renal angiomyolipoma is presented. Case Report: A 33-year-old female Caucasian patient, with a known medical history of tuberous sclerosis, was admitted to hospital as an emergency, with right-sided abdominal pain. Abdominal computed tomography (CT) imaging showed bilateral renal tumors, consistent with bilateral renal angiomyolipoma. The larger tumor, involving the enlarged right kidney (24.0 cm in length), had a diameter of 21.0 cm and was associated with hemoperitoneum and retroperitoneal hemorrhage, and contrast 'blush' on CT confirmed arterial bleeding. An initial urgent exploratory laparotomy with renal packing was initially performed, but right nephrectomy was required for hemorrhage control. The patient was discharged from hospital on the 23 rd postoperative day, without further complications. Conclusions: This report describes a case of Wunderlich's Syndrome, or spontaneous retroperitoneal hemorrhage, in a patient with tuberous sclerosis and bilateral renal angiomyolipoma, presenting as an emergency. An early diagnosis and timely treatment are important in cases of retroperitoneal hemorrhage to prevent life-threatening complications.
Small Bowel Obstruction Due to Incarcerated Obturator Hernia: Successfull Surgical Management with Modified Mesh-Plug Hernioplasty
The American Journal of Case Reports, 2021
Patient: Female, 93-year-old Final Diagnosis: Incarcerated obturator hernia Symptoms: Diffuse abd... more Patient: Female, 93-year-old Final Diagnosis: Incarcerated obturator hernia Symptoms: Diffuse abdominal pain Medication:— Clinical Procedure: Hernioplasty Specialty: Surgery Objective: Rare disease Background: Obturator hernia is an uncommon (0.07-1% incidence rate) subtype of hernia of the abdominal wall, with its incarceration being a rare cause of bowel obstruction. Obturator hernia has a higher incidence in elderly women and in malnourished people. This type of hernia has the highest morbidity and mortality rates of all abdominal wall hernias. This article reports a case of an emaciated 93-year-old woman who presented with small bowel obstruction due to incarcerated obturator hernia, successfully managed surgically with a modified mesh-plug hernioplasty. Case Report: An emaciated 93-year-old woman presented with diffuse abdominal pain, more intense on the right iliac fossa, radiating to the right thigh, with 8-h evolution and associated with dark-colored vomiting but normal bowe...
Retroperitoneal mature cystic teratoma involving the left adrenal gland in a 75-year-old male: a case report and literature review
Primary retroperitoneal teratomas involving adrenal glands are extremely uncommon, particularly i... more Primary retroperitoneal teratomas involving adrenal glands are extremely uncommon, particularly in elderly males. Only a few case reports have been documented in the literature so far. We report a mature cystic retroperitoneal teratoma in the region of left adrenal gland in an asymptomatic 75-year-old male patient. It was incidentally found on an abdominal computed tomography scan and was thought to be an adrenal adenoma. Because of its relatively large size and the patient’s request, he underwent a laparoscopic left adrenalectomy. Histopathological examination revealed a benign mature cystic retroperitoneal teratoma in the region of the left adrenal gland. The patient had an uneventful postoperative course and is free of recurrence after 20 months of follow-up. Considering the diagnostic difficulty of retroperitoneal teratoma by radiologic imaging, and its risk of malignancy, surgical resection via a minimally invasive approach would be the best diagnostic and therapeutic option. A...
Gastro-gastric Fistula: a Rare Complication of Gastric Banding
Indian Journal of Surgery
Gastric banding was a common procedure over the last decades, but, because of its poor results in... more Gastric banding was a common procedure over the last decades, but, because of its poor results in weight loss and frequent complications, it has been avoided. A rare complication of this surgical technique is the formation of a gastro-gastric fistula. The authors report a case of an obese woman who underwent gastric banding, and, due to the onset of epigastric discomfort and sporadic vomiting, the band was removed. The patient persisted with the symptoms, and a gastro-gastric fistula was diagnosed. Our surgical approach was a laparoscopic Roux-en-Y gastric bypass with ligation of the fistula since the patient still had a body mass index of 37 kg/m2. Gastro-gastric fistula after gastric banding is a rare complication, and its diagnosis can be a challenge.There is no consensus on what surgical technique to use, but a laparoscopic Roux-en-Y gastric bypass with ligation of the fistula is a safe procedure if done by an experienced surgeon.
Congenital peritoneal encapsulation is a rare congenital malformation in which all or part of the... more Congenital peritoneal encapsulation is a rare congenital malformation in which all or part of the small bowel is covered by a thin accessory peritoneal membrane. Despite being usually asymptomatic and an incidental finding during surgery or autopsy, there is a small number of reports in the literature whose diagnosis was established in the context of intestinal obstruction. The authors review the topic and describe a case report undergoing surgery for intestinal obstruction. Intraoperatively, there was a partial peritoneal encapsulation of the small bowel with signs of intestinal malrotation. Peritoneal membrane excision, terminal ileum release and complementary appendicectomy were performed. There was a favorable clinical evolution in the postoperative period. Although rare, it is important to remember this entity in the differential diagnosis of patients with intestinal obstruction, in the absence of other etiologic factors.
Journal of Surgical Case Reports
Small bowel adenocarcinomas are rare malignant tumors that account for less than 2% of gastrointe... more Small bowel adenocarcinomas are rare malignant tumors that account for less than 2% of gastrointestinal tumors. Despite a thorough history, physical examination and complete diagnostic workup, the correct diagnosis of small intestinal neoplasm has been established preoperatively in only 50% of cases. Due to the rarity of this disease, there are very few established guidelines for its management and it has been primarily treated the same way as colorectal cancer, even though patient’s prognostic outcome is worse. With new guidelines in 2020, we review a clinical case of a 64-year-old male patient with adenocarcinoma of the jejunum treated in our institution.
Journal of Surgical Case Reports
Endometrial carcinoma is one of the most common gynaecologic malignancies in the western society.... more Endometrial carcinoma is one of the most common gynaecologic malignancies in the western society. Treatment of recurrent disease became more refined, with the study of molecular and hormonal receptors playing a central role. A 76-year-old caucasian woman presented to the emergency department with growing tiredness, and melaena. Past medical history included an endometrioid adenocarcinoma. The patient had undergone a hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymphadenectomy and was disease-free for 2 years. The endoscopy revealed an ulcerated lesion involving the second and third portions of the duodenum. Histopathologic examination confirmed a poorly differentiated adenocarcinoma of endometrial origin. She started palliative chemotherapy, remaining with adequate symptomatic control. Endometrial cancer recurrence typically occurs locally. The liver is the intra-abdominal organ most commonly involved. There are scarce reports of duodenal metastasis o...
Surgical approach to flail chest: 3 clinical cases
European Journal of Molecular & Clinical Medicine
Introduction Flail chest is a severe life threatening injury with mortality rates reaching up to ... more Introduction Flail chest is a severe life threatening injury with mortality rates reaching up to 33%, traditionally treated with mechanical ventilation (“internal fixation”). Recently, some authors recommend a surgical approach for highly unstable flail chest. Several rib fixation techniques have been described although none are considered gold standard. Despite growing evidence of benefits for both the patient as well as the hospital, there is a general reluctance to perform rib fixation. In smaller hospitals such as the one referred to in this text, general surgeons are called to manage these patients and as such, it is a prerequisite of their training to be aware of all available treatment options, including standard and novel surgical solutions for flail chest injury. Case description The 3 cases involved polytrauma victims who have undergone emergency laparotomy because of abdominal injuries. Rib osteosyntheses were undertaken once the patients were haemodynamically stable. Perforated metal plates and screws were used in all cases. All patients were readily weaned off from ventilation with no post-surgical complications from the osteosynthesis and were subsequently discharged home well. All patients remain asymptomatic and no complications were registered during a 17 months (average) follow up. Conclusion Surgical fixation of fractured ribs is a straightforward procedure which promotes reestablishment of ventilatory dynamics. Despite several studies favouring the surgical approach to flail chest, many surgeons are still reluctant to perform this procedure. The authors present a simple and reproducible technique, with good results.
HPB, 2019
In the logistic regression model, LNY and tumor size positively correlated with N1 stage. Conclus... more In the logistic regression model, LNY and tumor size positively correlated with N1 stage. Conclusion: SPE is associated with higher LNY in patients with PAC, which increases the likelihood of detecting positive lymph nodes and reduces the risk of understaging. These findings also indicate that ST is adequate.
An 80-year-old female patient, with obesity and arterial hypertension, was admitted to our emerge... more An 80-year-old female patient, with obesity and arterial hypertension, was admitted to our emergency department, for periumbilical pain and constipation in the last 6 days. She presented with abdominal distension and a large irreducible hernia in her right lower quadrant. She had an abdominal Computerized Tomography (CT) done that confirmed the clinical suspicion of a Spiegel hernia, containing colon and a large quantity of omentum (Figure 1). She underwent an urgent surgery (Figure 2): laparoplasty with a dual surface mesh, and was discharged home on the 4th post-operative day. She remains asymptomatic, with no hernia relapse. The diagnosis of this hernia requires a high suspicion index and the CT is the best imaging study for their characterization. The incarceration risk of this hernia is high. Thirty percent of these patients require an urgent surgery. Hence, surgery is recommended for all patients presenting with a Spiegel hernia.
International Journal of Surgery Case Reports, 2020
INTRODUCTION: Most abdominal cysts derive from the ovary. The range of differential diagnoses is ... more INTRODUCTION: Most abdominal cysts derive from the ovary. The range of differential diagnoses is wide. Unfortunately, imaging studies not always determine its origin. PRESENTATION OF CASE: The authors present the case of a 20-year-old female patient, admitted to the emergency department due to abdominal pain and distension, whose imaging studies revealed a gigantic abdominal cyst of unknown origin. She underwent an exploratory laparotomy that disclosed an ovarian cyst that was removed by a left adnexectomy. It weighed 10Kg and was 60 cm wide. The pathology report showed a mucinous cyst adenoma. DISCUSSION: Once a patient present with an abdominal cyst, one should always consider the extensive list of differential diagnoses. In premenopausal women, ovarian cysts are very frequent. Cysts may grow to considerable size. Our patient was symptomatic, malnourished and dehydrated. Neither ultrasonography nor computed tomography were able to define the origin of the cyst. Persistent ovarian cysts larger than 10 cm, particularly if symptomatic, should be considered for surgery. CONCLUSION: Progressive abdominal distension in premenopausal women should raise suspicion of an ovarian tumor, such as mucinous cystadenoma. These tumours are benign, but when their size is considerable, complications do arise and their surgical removal may be life threatening.
HPB, 2019
up on the pancreatic pathoanatomy. Most patients with such findings have inoperable conditions, h... more up on the pancreatic pathoanatomy. Most patients with such findings have inoperable conditions, however very rarely inflammatory pseudotumors can mimick their appearance and surgical exploration provides the necessary safety to conduct a cortisone therapy that would be detrimental otherwise.
Journal of Surgical Case Reports, 2019
Spontaneous posterior rectus sheath hernia is perhaps one of the rarest hernias described only in... more Spontaneous posterior rectus sheath hernia is perhaps one of the rarest hernias described only in a few published cases. We present the case of a small bowel herniation through the posterior rectus sheath in a woman without previous abdominal surgical history, resulting in acute small bowel obstruction who was successfully treated by laparoscopy. This is the first case report of this kind of hernia managed with laparoscopic technique. Although the laparoscopic approach is not considered standard treatment for strangulated hernias, in selected cases, it allows the identification and repair of the defect.
Case Reports in Surgery, 2019
Gastrointestinal stromal tumors (GIST) comprised 0,2% of all GI tumors. They are typically asympt... more Gastrointestinal stromal tumors (GIST) comprised 0,2% of all GI tumors. They are typically asymptomatic, but can manifest with nonspecific GI symptoms, GI bleeding, or intussusception. The authors report a case of a 55-year-old female patient with hematochezia and a palpable mass on the left lower quadrant. Ultrasound revealed possible intussusception. However, CT scan did not show any signs of lesions or intussusception. On reevaluation, the mass was no longer palpable. The patient had recurrent episodes of hematochezia with need of transfusional support. CT enterography revealed a 20-24 mm jejunoileal lesion. A laparotomy was undertaken with small bowel resection containing the lesion. Histological examination confirmed GIST. GIST presentation as transient intussusception and intermittent GI bleeding is rare. This case report emphasizes the rarity of jejunoileal GIST, its clinical details, diagnostic study, and treatment.
Journal of surgical case reports, 2018
The progresses made in minimally invasive surgery, make it not only possible to perform isolated ... more The progresses made in minimally invasive surgery, make it not only possible to perform isolated cholecystectomy, but also to provide a totally laparoscopic treatment of common bile duct lithiasis. In this approach, the use of choledochoscopy is indispensable for diagnostic and therapeutic success. This study describes the use of a disposable endoscope for choledochoscopy in the laparoscopic treatment of choledocholithiasis. We have analyzed the use of the Ambu aScope 3 disposable endoscope, normally used for bronchoscopy, in nine consecutive patients needing choledochoscopy in our Hospital. The patient average age was 78 years. Total clearance of the bile duct was obtained in seven patients. Bile duct vacuity was not obtained in two patients, but this is not attributed to equipment failure. There was one case of hemoperitoneum not related to equipment usage. This device is easy to use and looks promising for choledochoscopy in laparoscopic treatment of coledocholithiasis.
Journal of surgical case reports, 2018
Wilkie's syndrome, or superior mesenteric artery syndrome (SMAS), is a rare clinical entity c... more Wilkie's syndrome, or superior mesenteric artery syndrome (SMAS), is a rare clinical entity caused by compression of the third portion of the duodenum between the abdominal aorta and superior mesenteric artery, leading to duodenal obstruction and severe malnutrition. The authors report a case of a female patient with years of chronic intestinal obstruction with abdominal pain, vomits and weight loss. Contrast intestinal series showed dilation of stomach and duodenum. Abdominal computed tomography study revealed findings compatible with SMAS. After initial nutritional support, she was successfully treated by laparoscopic duodenojejunostomy. Surgical treatment of SMAS may be necessary in most cases with chronic symptoms or conservative treatment failure. A minimally invasive approach can be considered a safe surgical option with favourable outcomes. Clinical details, diagnostic studies and treatment are discussed.
Journal of Surgical Case Reports, 2020
Von Recklinghausen disease (neurofibromatosis type 1—NFT1) is a genetic disorder with autosomal d... more Von Recklinghausen disease (neurofibromatosis type 1—NFT1) is a genetic disorder with autosomal dominant inheritance pattern, caused by mutation of a tumour suppressor gene. Its main features include multiple cutaneous café-au-lait spots and neurofibromas. It is associated with an increased risk of developing neuroendocrine tumours, for instance, in the duodenum. The authors present a case of a 23-year-old male patient admitted to the emergency department due to persistent vomiting. Imaging and biopsy studies revealed an obstructive and large duodenal neuroendocrine tumour; hence the patient underwent a pancreaticoduodenectomy.
International journal of surgery case reports, 2018
Acute appendicitis is the main indication for surgery during pregnancy. Physiologic changes durin... more Acute appendicitis is the main indication for surgery during pregnancy. Physiologic changes during pregnancy and fear of using ionising radiation exams are some of the reasons to delayed diagnosis and consequently to higher morbidity and mortality rates for mother and fetus. We present the case of a 38-year-old woman that resorted to the emergency room on the 13th week of pregnancy with abdominal discomfort, nausea and vomiting that lasted for 7 days. She had been in the Obstetric Emergency Department 6 days prior with the same complaints. She had no fever and she was discharged home following normal obstetric ultrasound. On this second visit, after surgical consultation, septic shock with abdominal source was recognised and patient was taken for emergency exploratory laparotomy. Intraoperatively we found generalised purulent peritonitis secondary to perforated acute appendicitis. Appendectomy, thorough abdominal washing and laparostomy were performed. Patient was admitted on the In...
Cureus, 2021
Non-islet cell tumor hypoglycemia is a rare paraneoplastic condition caused by an extra-pancreati... more Non-islet cell tumor hypoglycemia is a rare paraneoplastic condition caused by an extra-pancreatic tumor. We report a rare case of hypoglycemia caused by a relapsing pelvic solitary fibrous tumor associated with Big-IGF-2 production. A 72-year-old woman was admitted to our hospital because of loss of consciousness and hypoglycemia. She had a history of ovarian solitary fibrous tumor, which has relapsed. From investigation, serum levels of insulin and C-peptide were suppressed; IGF-1 was slightly reduced and IGF-2 was within the normal range, but the IGF-2: IGF-1 ratio was elevated, indicating the presence of Big-IGF-2 secreting non-islet cell tumor. Contrast-enhanced computed tomography (CT) showed a large pelvic mass. She was then submitted to surgical resection of the mass, which histologically proved to be a solitary fibrous tumor. Three months later, she remains asymptomatic. Non-islet cell tumor hypoglycemia should be considered in the differential diagnosis of patients presenting with tumors and recurrent hypoglycemia.
International Journal of Surgery Case Reports, 2019
INTRODUCTION: Boerhaave's syndrome is a life-threatening oesophageal perforation that carries a h... more INTRODUCTION: Boerhaave's syndrome is a life-threatening oesophageal perforation that carries a high mortality rate (20-50%). Diagnosis is difficult by its rarity and the absence of typical symptoms. Treatment of this condition usually requires surgical intervention. PRESENTATION OF CASE: We report the case of a 77-year-old man that resorted to the emergency room with dyspnoea and thoracic pain after vomiting. CT scan revealed pneumomediastinum, left collapse lung and loculated pleural effusion. A left intercostal chest tube was inserted with food drainage. Hence, Boerhaave's syndrome was suspected. Thoracotomy with mediastinum debridement, pleural drainage and oesophageal T-tube drainage was performed. Patient was admitted on the Intensive Care Unit with septic shock, with need for ventilatory support and vasopressor therapy. Two days later, a second look thoracotomy was done with definitive oesophageal repair and pleural patch. The post-operative course was complicated by pneumonia and stroke. Patient was discharged home on the 38th day and remains well at 3 month of follow-up. DISCUSSION: Delayed diagnosis and treatment are the principal causes of high mortality in Boerhaave's syndrome. The classic Mackler's triad (vomiting, lower thoracic pain and subcutaneous emphysema) is present in less then 50% of cases. A thoracic drainage may be useful to confirm diagnosis promptly. There is no standard treatment option. In this case report, the authors used a damage control approach to control sepsis, allowing for a delayed definitive oesophageal repair. CONCLUSION: Prompt diagnosis with thoracic drainage and a damage control treatment plan might lead to good prognosis for patients with this rare and potentially fatal condition.
American Journal of Case Reports
Rare disease Background: Wunderlich's syndrome, or spontaneous non-traumatic retroperitoneal hemo... more Rare disease Background: Wunderlich's syndrome, or spontaneous non-traumatic retroperitoneal hemorrhage, can be a life-threatening event. Renal angiomyolipoma is a rare benign tumor that can occur sporadically, or in association with tuberous sclerosis. A case of spontaneous retroperitoneal hemorrhage in a patient with tuberous sclerosis and bilateral renal angiomyolipoma is presented. Case Report: A 33-year-old female Caucasian patient, with a known medical history of tuberous sclerosis, was admitted to hospital as an emergency, with right-sided abdominal pain. Abdominal computed tomography (CT) imaging showed bilateral renal tumors, consistent with bilateral renal angiomyolipoma. The larger tumor, involving the enlarged right kidney (24.0 cm in length), had a diameter of 21.0 cm and was associated with hemoperitoneum and retroperitoneal hemorrhage, and contrast 'blush' on CT confirmed arterial bleeding. An initial urgent exploratory laparotomy with renal packing was initially performed, but right nephrectomy was required for hemorrhage control. The patient was discharged from hospital on the 23 rd postoperative day, without further complications. Conclusions: This report describes a case of Wunderlich's Syndrome, or spontaneous retroperitoneal hemorrhage, in a patient with tuberous sclerosis and bilateral renal angiomyolipoma, presenting as an emergency. An early diagnosis and timely treatment are important in cases of retroperitoneal hemorrhage to prevent life-threatening complications.
Small Bowel Obstruction Due to Incarcerated Obturator Hernia: Successfull Surgical Management with Modified Mesh-Plug Hernioplasty
The American Journal of Case Reports, 2021
Patient: Female, 93-year-old Final Diagnosis: Incarcerated obturator hernia Symptoms: Diffuse abd... more Patient: Female, 93-year-old Final Diagnosis: Incarcerated obturator hernia Symptoms: Diffuse abdominal pain Medication:— Clinical Procedure: Hernioplasty Specialty: Surgery Objective: Rare disease Background: Obturator hernia is an uncommon (0.07-1% incidence rate) subtype of hernia of the abdominal wall, with its incarceration being a rare cause of bowel obstruction. Obturator hernia has a higher incidence in elderly women and in malnourished people. This type of hernia has the highest morbidity and mortality rates of all abdominal wall hernias. This article reports a case of an emaciated 93-year-old woman who presented with small bowel obstruction due to incarcerated obturator hernia, successfully managed surgically with a modified mesh-plug hernioplasty. Case Report: An emaciated 93-year-old woman presented with diffuse abdominal pain, more intense on the right iliac fossa, radiating to the right thigh, with 8-h evolution and associated with dark-colored vomiting but normal bowe...
Retroperitoneal mature cystic teratoma involving the left adrenal gland in a 75-year-old male: a case report and literature review
Primary retroperitoneal teratomas involving adrenal glands are extremely uncommon, particularly i... more Primary retroperitoneal teratomas involving adrenal glands are extremely uncommon, particularly in elderly males. Only a few case reports have been documented in the literature so far. We report a mature cystic retroperitoneal teratoma in the region of left adrenal gland in an asymptomatic 75-year-old male patient. It was incidentally found on an abdominal computed tomography scan and was thought to be an adrenal adenoma. Because of its relatively large size and the patient’s request, he underwent a laparoscopic left adrenalectomy. Histopathological examination revealed a benign mature cystic retroperitoneal teratoma in the region of the left adrenal gland. The patient had an uneventful postoperative course and is free of recurrence after 20 months of follow-up. Considering the diagnostic difficulty of retroperitoneal teratoma by radiologic imaging, and its risk of malignancy, surgical resection via a minimally invasive approach would be the best diagnostic and therapeutic option. A...
Gastro-gastric Fistula: a Rare Complication of Gastric Banding
Indian Journal of Surgery
Gastric banding was a common procedure over the last decades, but, because of its poor results in... more Gastric banding was a common procedure over the last decades, but, because of its poor results in weight loss and frequent complications, it has been avoided. A rare complication of this surgical technique is the formation of a gastro-gastric fistula. The authors report a case of an obese woman who underwent gastric banding, and, due to the onset of epigastric discomfort and sporadic vomiting, the band was removed. The patient persisted with the symptoms, and a gastro-gastric fistula was diagnosed. Our surgical approach was a laparoscopic Roux-en-Y gastric bypass with ligation of the fistula since the patient still had a body mass index of 37 kg/m2. Gastro-gastric fistula after gastric banding is a rare complication, and its diagnosis can be a challenge.There is no consensus on what surgical technique to use, but a laparoscopic Roux-en-Y gastric bypass with ligation of the fistula is a safe procedure if done by an experienced surgeon.
Congenital peritoneal encapsulation is a rare congenital malformation in which all or part of the... more Congenital peritoneal encapsulation is a rare congenital malformation in which all or part of the small bowel is covered by a thin accessory peritoneal membrane. Despite being usually asymptomatic and an incidental finding during surgery or autopsy, there is a small number of reports in the literature whose diagnosis was established in the context of intestinal obstruction. The authors review the topic and describe a case report undergoing surgery for intestinal obstruction. Intraoperatively, there was a partial peritoneal encapsulation of the small bowel with signs of intestinal malrotation. Peritoneal membrane excision, terminal ileum release and complementary appendicectomy were performed. There was a favorable clinical evolution in the postoperative period. Although rare, it is important to remember this entity in the differential diagnosis of patients with intestinal obstruction, in the absence of other etiologic factors.
Journal of Surgical Case Reports
Small bowel adenocarcinomas are rare malignant tumors that account for less than 2% of gastrointe... more Small bowel adenocarcinomas are rare malignant tumors that account for less than 2% of gastrointestinal tumors. Despite a thorough history, physical examination and complete diagnostic workup, the correct diagnosis of small intestinal neoplasm has been established preoperatively in only 50% of cases. Due to the rarity of this disease, there are very few established guidelines for its management and it has been primarily treated the same way as colorectal cancer, even though patient’s prognostic outcome is worse. With new guidelines in 2020, we review a clinical case of a 64-year-old male patient with adenocarcinoma of the jejunum treated in our institution.
Journal of Surgical Case Reports
Endometrial carcinoma is one of the most common gynaecologic malignancies in the western society.... more Endometrial carcinoma is one of the most common gynaecologic malignancies in the western society. Treatment of recurrent disease became more refined, with the study of molecular and hormonal receptors playing a central role. A 76-year-old caucasian woman presented to the emergency department with growing tiredness, and melaena. Past medical history included an endometrioid adenocarcinoma. The patient had undergone a hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymphadenectomy and was disease-free for 2 years. The endoscopy revealed an ulcerated lesion involving the second and third portions of the duodenum. Histopathologic examination confirmed a poorly differentiated adenocarcinoma of endometrial origin. She started palliative chemotherapy, remaining with adequate symptomatic control. Endometrial cancer recurrence typically occurs locally. The liver is the intra-abdominal organ most commonly involved. There are scarce reports of duodenal metastasis o...
Surgical approach to flail chest: 3 clinical cases
European Journal of Molecular & Clinical Medicine
Introduction Flail chest is a severe life threatening injury with mortality rates reaching up to ... more Introduction Flail chest is a severe life threatening injury with mortality rates reaching up to 33%, traditionally treated with mechanical ventilation (“internal fixation”). Recently, some authors recommend a surgical approach for highly unstable flail chest. Several rib fixation techniques have been described although none are considered gold standard. Despite growing evidence of benefits for both the patient as well as the hospital, there is a general reluctance to perform rib fixation. In smaller hospitals such as the one referred to in this text, general surgeons are called to manage these patients and as such, it is a prerequisite of their training to be aware of all available treatment options, including standard and novel surgical solutions for flail chest injury. Case description The 3 cases involved polytrauma victims who have undergone emergency laparotomy because of abdominal injuries. Rib osteosyntheses were undertaken once the patients were haemodynamically stable. Perforated metal plates and screws were used in all cases. All patients were readily weaned off from ventilation with no post-surgical complications from the osteosynthesis and were subsequently discharged home well. All patients remain asymptomatic and no complications were registered during a 17 months (average) follow up. Conclusion Surgical fixation of fractured ribs is a straightforward procedure which promotes reestablishment of ventilatory dynamics. Despite several studies favouring the surgical approach to flail chest, many surgeons are still reluctant to perform this procedure. The authors present a simple and reproducible technique, with good results.