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The surgical literature contains few reports about effects of hypothyroidism in patients with acute abdomen; has been reported that a glycoprotein infiltrate the lining of the bowel leading to denervation. We report the case of a woman with acute abdomen secondary to pyosalpynx with uncontrolled hypothyroidism postoperative complications.Hypothyroidism is called "big mimicker"because its clinic spectrum ranges from anasymptomatic subclinical condition to the rare,life-threatening myxedema coma, and thus can bea challenging diagnosis to make. Unrecognized hypothyroidism may lead to unnecessary surgery or even a potentially fatal outcome. A heightened awareness of this not so uncommon entity is mandatory

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OBJECTIVE: To report the experience with intestinal plication in patients with adhesive intestinal obstruction that was followed up to 12 years. BACKGROUND: To diminish the high recurrence rate of adhesive intestinal obstruction, there are surgical techniques of intestinal plication. In 1977 Blanco modified a pre-existing transmesenteric technique that is the used in our institution. METHOD: We studied the medical records of 32 patients who underwent intestinal plication using the transmesenteric technique. The postoperative evaluation was based in recurrence and mortality. RESULTS: There were 32 patients, 56% women and 44% men, with a mean age of 50 years. All patients had a history of intraabdominal surgical procedures. The postoperative evaluation was satisfactory. The success rate was over 90%. The recurrence rate was 9.3% and we had no mortality. The mean follow-up was 3.5 years (median 3 [range 1-12] years). There were no significant differences between this technique and the Noble and Childs-Phillips plication techniques. CONCLUSIONS: This technique of intestinal plication is useful in the surgical management of patients with adhesive intestinal obstruction.

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OBJECTIVE: To present a case of esophagic perforation due to a pneumatic dilatations of the cardias in a patient with achalasia. BACKGROUND: Achalasia of the esophagus is a primary motor alteration with an unknown cause. The principal characteristics are the lower or absent peristaltic waves in the esophagic body and the impared lower esophagic sphincter relaxation during deglution. The management is palliative with pneumatic dilatations, pharmacologic therapy or with surgery. When a esophagic perforation occurs, it must be diagnosed and treated as soon as possible because a delay in diagnosis and management affect directly the patient prognosis. METHOD: To present a case of esophagic perforation due to pneumatic dilatations of the cardias in a patient with achalasia. CONCLUSIONS: An useful palliative management for achalasia is the pneumatic forceful dilatation, however it carries some risk of perforation; in every patient who was treated with dilatations is mandatory to think in perforation when the clinical condition is different after the procedure. The success of surgical management of the perforated esophagus and the control of sepsis and mediastinitis depends directly of the clinical condition of the patient and the time within perforation and surgical therapy.

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OBJECTIVE: We report a case of retrograde jejunogastric intussusception in a patient with previous gastric surgery who required surgical treatment for its resolution. BACKGROUND: While intussusception is relatively common in children, it is infrequently seen in adults. Five percent of all cases occur in adults and in 90% of these, there is a lead point, a well-definable pathologic abnormality. Retrograde jejunogastric intussusception is a rare complication after gastrojejunostomy. The most common symptoms are pain, nausea, vomiting and blood per rectum. Diagnosis of adult intussusception is often difficult and is base in clinical suspicion and noninvasive techniques. METHOD: A case of a retrograde intussusception in a patient after gastric surgery who presented with abdominal pain and gastrointestinal bleeding. RESULTS: The patient underwent surgical treatment with reduction of the intussusception. The postoperative evolution was satisfactory. CONCLUSIONS: Management of intussuception in adults is usually laparotomy and in 90% of cases, a pathologic lesion will be identified. Retrograde jejunogastric intussusception is also managed surgically and simple reduction is the accepted form of treatment in most cases.

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BACKGROUND: Dynamic pancreatography (DP) can establish the development of tissue damage and demonstrate pancreatic necrosis (PN). OBJECTIVE: To prospectively evaluate the usefulness of DP in patients with acute pancreatitis (AP), analyzing its capabilities for determining the incidence of necrosis, and as a prognostic predictor. MATERIAL AND METHODS: All patients with AP seen at our department during 4 years were included. All patients were scheduled to DP. Findings were classified in five groups: I, interstitial AP; II, secondary fluid collections; III, peripancreatic necrosis; IV, pancreatic necrosis < 50% and pancreatic necrosis > 50%. Also included for analysis were: demographic variables, etiology, APACHE-II score, and Ranson's signs; when infection was suspected, cultures were done. PD and operative findings were correlated to calculate sensibility (S), specificity (Sp), positive and negative predictive values (PPV, NPV), and the diagnostic accuracy (DA) of the test. Correlation between severity/mortality and morphologic alterations according to the classified group were also performed. RESULTS: 244 patients. Biliary associated pancreatitis in 47% and alcohol induced in 37%. DP in 207 patients showed, 34 patients in group I; 36 in group II, 67 in group III, 47 and 60 in groups IV and V, respectively. Secondary pancreatic infection was present in 48%. One hundred seventy-two patients underwent surgery; the surgical indication was to interrupt the pathogenesis of complications in 52%. DP correlated with the prognostic signs and APACHE-II score as predictors of complications with an overall (S) of 93%, (Sp) 98%, (PPV) 91%, (NPV) 98%, and (DA) 97%. Greater scores values are all directly proportional with PD necrosis findings (P < 0.05). There was not PD related morbidity. CONCLUSIONS: We found correlation between PD classification and prognostic factors. Morphologic alterations were accurately identified. PD as preoperative work-up allows surgeons design operative strategies and as is useful follow-up of the patients after necrosectomy.

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OBJECTIVE: Report two cases of gastrointestinal neurofibromatosis that required surgical intervention for their resolution. BACKGROUND: Neurofibromatosis is a congenital disease which is classified in two types. In neurofibromatosis type 1 or Von Recklinghausen's disease the patients have some classical manifestations as cafe au lait pigmentation, bony abnormalities and neurofibromas of both peripheral and central nerves. In up to 25% of the patients with neurofibromatosis 1, the gastrointestinal tract is involved. The most affected organs are the stomach and the jejunum. The symptoms of the patients with gastrointestinal neurofibromatosis are related to gastrointestinal bleeding or obstruction. METHOD: Two patients with gastrointestinal neurofibromatosis that required surgical intervention for the resolution of their manifestations. RESULTS: Two cases of gastrointestinal neurofibromatosis, one of them had as her main clinical feature gastrointestinal bleeding, and the other patient intestinal obstruction. They were submitted to exploratory laparotomy finding gastrointestinal neurofibromatosis in both as the cause of their symptomatology. CONCLUSIONS: The management of gastrointestinal neurofibromatosis could need surgical intervention, and when this is done the postoperative evolution is satisfactory.

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Acute mesenteric ischemia is an abdominal emergency due to inadequate tissue perfusion with a mortality rate between 60 and 100%. Intestinal damage by ischemia depends on general circulation, collateral blood flow, response of the mesenteric vasculature to autonomic stimuli, circulating vasoactive substances, local humoral factors, and the normal and abnormal products of cellular metabolism before and after reperfusion of the ischemic segment. Four physiopathologic phenomenon are present: superior mesenteric artery embolism; superior mesenteric artery thrombosis; non-occlusive acute mesenteric ischemia, and superior mesenteric venous thrombosis; embolism event is the most frequent. The injury observed after 3 of ischemia (blood flow reduced to 20% of normal) and 1 of reperfusion is more severe than 4 of ischemia. Clinical diagnosis of mesenteric ischemia required a high suspect index, specially in elderly patients with cardiovascular problems. Abdominal pain and hemodynamic and/or metabolic changes are the most frequent symptoms. Although some authors have questioned the need for angiography, this study is the key not only to making a diagnosis of acute mesenteric ischemia before bowel infarction and prior to laparotomy, but also to initiate intra-arterial mesenteric angiography therapy with vasodilators. Patients who persist with acute abdomen will require exploratory celiotomy and vascular exploration. The outcome depends on early diagnosis and therapy to avoid ischemia progression and reperfusion injury.

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BACKGROUND DATA: Surgery stays as the only effective therapy against gastric cancer. Several factors have been postulated to influence morbidity and mortality risk in gastric cancer surgery. OBJECTIVE: Determine morbidity and mortality of gastric cancer surgery and establish risk factors. METHOD: We reviewed the charts of patients who underwent surgery for gastric adenocarcinoma. Morbidity and mortality is reported. Demographic factors, preoperative physical evaluation, biochemical parameters, surgical technique and tumor biology were analyzed as risk factors for morbidity and mortality. RESULTS: During a seven year period, 120 patients were operated for gastric cancer. Median age was 58.07 years. Subtotal gastrectomy was the most common surgical procedure in 51 patients (42.5%). Morbidity was 26.66% (n = 32). Medical most common complication was renal failure (n = 6, 14.63%) and surgical most common complication was wound infection (n = 7, 17.07%). Mortality was 13.33% (n = 16). Statistically significant risk factors for morbidity were age, ECOG status, Goldman Cardiac Risk Index and a total lymphocyte count. Statistically significant risk factors for mortality were Goldman Cardiac Risk Index, albumin, creatinine, and total lymphocyte count. CONCLUSIONS: Morbidity and mortality after gastric cancer surgery is influenced by preoperative conditions of patients.

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BACKGROUND DATA: Gastrointestinal stromal tumors (GIST) are considered the most common group of non-epithelial neoplasms of stomach and small bowel. OBJECTIVE: To present a case report and literature review. METHOD: Sixty-seven year-old white male with abdominal mass and gastrointestinal bleeding. Laboratory and X-ray test were done resulting in gastric leiomyosarcoma suspect. RESULTS: Patient underwent to exploratory celiotomy with subtotal gastrectomy with splenectomy. Immunohistochemistry results confirms gastrointestinal stromal tumor diagnosis of the stomach.

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OBJECTIVE: To describe the clinical presentation and treatment of two patients with the Klippel-Trenaunay syndrome referred to our hospital because of rectal bleeding and to review the literature concerning the diagnosis and treatment of this complication. CASE 1: Fifteen year old male with the Klippel-Trenaunay syndrome and chronic anemia who presented with severe rectal bleeding. CASE 2: Nineteen year old female with the same syndrome and a two year history of intermittent rectal bleeding, anemia and thrombocytopenia. In both cases the study protocol revealed varicose lesions in the colon as the cause of bleeding and other vascular malformations related to their syndrome. TREATMENT: The first patient was treated with partial colectomy and colorectal anastomosis. Four years after surgery he presented with new episodes of bleeding and was treated with sclerosis of the residual rectal varices using formaldehyde. The second patient was treated with partial colectomy and colostomy. She has received to sessions of sclerosis with absolute alcohol of the residual varices in the rectal stump. Colostomy closure is soon to be performed. CONCLUSION: Klippel-Trenaunay syndrome is a rare clinical entity with vascular alterations at different levels. A small percentage of cases may present rectal bleeding due to colonic varices and can lead to chronic anemia or severe hemorrhage with hemodynamic implications. Treatment of this complication involves resection of the affected colonic segment combined with a secondary procedure to control bleeding of the residual rectal varices.

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The objective of the present study was to determine the type, frequency and severity of the side effects of a low-molecular-weight heparin (LMWH) during the prophylaxis of thromboembolic disease (TED) after abdominal surgery. The study was prospective, comparative, longitudinal, and open. The setting was at the surgical and hematology services of a teaching hospital. There were 57 patients (27 males, 30 females) with risk factors for TED, including gastrointestinal malignancies. Seventeen patients (Group A) received LMWH, 20 mg/day; 20 (Group B) standard heparin (SH), 5,000 U/12 h, and 20 (Group C) formed the control group. LMWH or SH were administered 2 h before surgery and then, when patients assumed complete ambulatory status, at the end of their hospital stay or for a maximum of ten days. There were no significant differences among the groups in relation with age, anthropometric variables, type and duration of surgery, nor in the extent of the surgical bleeding, days to full ambulatory status nor length of postoperative hospital stay. A similar number of erythrocyte transfusions were used on the three groups. Eighty-three percent of the patients were 50 years of age or older. None developed TED. Postoperatively in group "A" a significant increase in platelets (p = 0.01) was found, as was the shortening of the activated partial thromboplastin time (P = 0.007); other adverse effects did not occur during the administration of LMWH. These findings allowed us to conclude that LMWH constitutes a safe, reliable and comfortable alternative for prophylaxis of TED in this type of surgical patients.

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PURPOSE: A surgical technique is presented which creates an intestinal valve. METHODS: In six dogs, the terminal ileum and the ascending colon were removed and the valve was made. The valve has been constructed in eight humans, three of them were cases of short bowel syndrome with resection of the ileocecal valve and five cases were right hemicolectomies attributable to a carcinoma of the cecum and ascending colon. RESULTS: The dogs were observed for a period of four to six months, during which time the animals stayed healthy. In the cases of short bowel syndrome in humans, the valve reduced the number of evacuations, in the five cases of right hemicolectomies the evolution was without complications. CONCLUSION: This surgical technique can be useful in the management of patients with morbidity by resection of the ileocecal valve.

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