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INTRODUCTION AND IMPORTANCE: The mediastinal ectopic thyroid gland is rare and usually asymptomatic. Ectopic thyroid tissue has malignant potential, but ectopic thyroid cancers are extremely rare, particularly mediastinal thyroid cancer, with only five cases reported in the literature. CASE PRESENTATION: A 73 years-old male patient diagnosed with multinodular goitre with two FLUS cytology was summited to an uneventful total thyroidectomy. Pathology revealed 8 synchronous papillary carcinomas in both thyroid lobes. Follow-up identified persistent elevation of thyroglobulin. A cervical ultrasound and cervical and thoracic CT scan were performed, identifying a mediastinal tumour of 6 × 3 cm. Resection was performed by video-assisted thoracic surgery (VATS). Pathology identified an ectopic mediastinal thyroid with a 4 mm papillary microcarcinoma. Recovery was uneventful and the patient is currently asymptomatic. CLINICAL DISCUSSION: There is no consensus on the best treatment strategy for mediastinal ectopic thyroid, but surgical resection is advised as being the only method allowing for a complete cure. Although both thoracotomy and sternotomy approaches have been usually used for mediastinal thyroid tumours resection, the thoracoscopic approach has been used with good results in recent years. Thoracoscopy has better visualization, less morbimortality, and faster recovery. Giant masses (>10 cm) are the only limitation for VATS. CONCLUSION: Ectopic mediastinal thyroid is extremely rare, and its malignant transformation is even rarer. There is no consensus on the best treatment strategy, but surgical resection of the mediastinal thyroid is advised. VATS is a safe and feasible minimally invasive technique with good outcomes.

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INTRODUCTION AND IMPORTANCE: Hepatic abscess due to foreign body is rare. Diagnosis is difficult and drainage may not be enough. Hepatic resection may be indicated. CASE PRESENTATION: A 76yo male patient resorted to the emergency room because of fever and abdominal pain. Abdominal CT diagnosed a hepatic abscess in the left lobe due to a fishbone. Percutaneous and surgical drainage failed. Laparotomic hepatic resection was necessary. The patient was discharged asymptomatic. CLINICAL DISCUSSION: Liver abscess due to foreign body usually occur in the left lobe. Drainage and removal of the foreign body are mandatory and can be achieved either by percutaneous or surgical drainage. Resection is rarely indicated but sometimes is the only way. The authors found only ten cases of hepatic resection due to pyogenic abscess because of a foreign body. CONCLUSIONS: Hepatic resection is rarely needed to treat a pyogenic abscess, but surgeons must be aware and able to proceed with it.

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INTRODUCTION: Posterior retroperitoneoscopic adrenalectomy (PRA) has advantages over transperitoneal approach. A second group of 10 patients is analyzed and compared with the first 10 procedures. Conclusions on feasibility, safety and learning curve are taken. MATERIAL AND METHODS: A retrospective analysis of a second group of 10 patients submitted to PRA was conducted. All patients with functioning and non-functioning adrenal tumors <6-8 cm and without features of malignancy were included. A comparison with the previous 10 cases was conducted, and the results of all 20 cases were compared with other surgeons. RESULTS: Pre-operative diagnoses: Conn's syndrome - 8 (80%); Pheochromocytoma - 1 (10%); Non-functioning tumor (≥ 4 cm) - 1 (10%). Mean size of adrenal tumors was 2,9 cm. Mean operative time for first group was 46,7 min and 31,1 min for the second (p = 0,036). Postoperative in-hospital days decreased in the second group (p = 0,01). Conversion rate was equal (10%). Morbidity and mortality were similar. DISCUSSION: Comparing the evolution of operative time in both groups, a constant and faster operative time was noted for the second group and a decreasing linear tendency was noted as more cases were being performed. Postoperative in-hospital days lowered in the second group, because with experience we started discharging patients earlier. Outcomes are stable between both groups. Our results match other authors data. CONCLUSION: These results are consistent with our first report and support the small learning curve for PRA, which is technically feasible and safe. Operative time and in-hospital days are influenced by surgeon's experience. More cases need to be collected so that these results can be validated.

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INTRODUCTION: Symmetrical peripheral gangrene (SPG) is a rare syndrome defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease. PRESENTATION OF CASE: A 45yo woman, admitted in intensive care unit due to urinary septic shock, in need of high doses of amines, developed cold extremities with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, liver shock, thrombocytopenia, prolonged coagulation times, increased D-Dimers and isolation of Acinetobacter baumanni in urine culture. An intravenous vasodilator was initiated with clinical benefits. After improvement and delimitation of the lesions, the patient underwent the amputation of the distal phalanges of the 2nd, 3rd and 4th fingers of the right hand and the toes of both feet. DISCUSSION/CONCLUSION: Even though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasodilators are used, in order to avoid major amputation.

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INTRODUCTION: Posterior retroperitoneoscopic adrenalectomy has advantages over transperitoneal technique. However many surgeons prefer the transperitoneal technique because they get a familiar and wider working space. MATERIAL AND METHODS: A retrospective analysis of the first 10 patients submitted to posterior retroperitoneoscopic adrenalectomy was conducted. Data collected included: diagnosis, size, operation time, blood loss, conversion rate, morbidity and mortality, in-hospital length of stay. Compare our outcomes with worldwide bigger series, and take conclusions on the feasibility of the technique was the objective. RESULTS: We included 2 pheochromocytomas, 1 giant cystic pheochromocytoma, 4 Conn's, 2 Cushing's, 1 non-functioning tumor with 4 cm. Mean operation time was 46,7 min for lesions ranging from 1,8 to 14 cm. Blood loss was negligible. One patient (10%) was converted to laparotomy because of a past clinical history of dorsal and lumbar trauma. No morbidity and no mortality. Mean hospital length of stay was 2,2 days. DISCUSSION: Mean operation time found in bigger series published in worldwide literature is 40-105,6 min. Complication rate reported ranges from 0 to 14,4%. No mortality has been ever reported. Blood loss reported in other series is 10-50 ml. The data found in our study matches other studies data. Since the same surgeon who had never performed the technique before operated all patients, makes us believe the technique is safe and feasible. CONCLUSION: Posterior retroperitoneoscopic adrenalectomy has a small learning curve. It is technically safe and feasible. More patients will be collected to validate these results.

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Abrikossoff's tumour or granular cell tumour is a rare entity. Most common locations are the head and neck, with only a few cases reported on the upper limbs. A 55-year-old man with a nodular lesion on the left arm resorted to surgery consultation. Nodule was firm, mobile, painless and non-ulcerated. Total excision using a Limberg flap procedure was performed. Following 3 months of follow-up, the patient is fine. Abrikossoff's tumour is frequently presented in the second to sixth decade of life as an ulcerated nodule with progressive growth. Malignant form is rare, with metastases occurring in up to 3% of patients. Excision must be accomplished with free margins. Recurrence is rare. Abrikossoff's tumour on the upper limbs is rare. Although benignity is the rule, doctors must be aware of the possibility of harbouring a cancer. Surgery is the treatment of choice.

Asunto(s)

Tumor de Células de la Granulosa/diagnóstico , Diagnóstico Diferencial , Tumor de Células de la Granulosa/diagnóstico por imagen , Tumor de Células de la Granulosa/cirugía , Humanos , Masculino , Persona de Mediana Edad , Colgajos Quirúrgicos , Extremidad Superior

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INTRODUCTION: Giant cystic pheochromocytoma (>10cm) is rare with only a few cases described in the literature. Preoperative diagnosis is very difficult because clinical, biochemical and radiologic finds are usually not consistent with a pheochromocytoma. Open surgery is traditionally the gold standard. CASE PRESENTATION: A 51 year-old male patient resorted to surgery department with an adrenal cystic incidentaloma. He was asymptomatic, mild hypertension easily controlled, with increased plasma fractionated metanephrines. MRI and MIBG scans confirmed the presence of a right adrenal giant cystic pheochromocytoma (14cm). A right posterior retroperitoneoscopic adrenalectomy was performed, complicated with an unintended disruption. At follow-up he was asymptomatic and with plasma fractionated metanephrines normalized. DISCUSSION: Although laparoscopic surgery is effective and safe, traditional open surgery is the gold standard in the presence of adrenal tumours with suspicion of malignancy, like masses larger than 8cm (including giant cystic pheochromocytomas). Minimal invasive techniques have the advantages of less postoperative pain and ileus, less morbidity, improved cosmetics, and faster recovery, but with the negative impact in R0 resection and probably a higher risk of cystic rupture. However comparisons between open and minimally invasive surgery are lacking. Additionally posterior retroperitoneoscopic approach has several advantages over laparoscopic transperitoneal method. CONCLUSION: This is the first case report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy, but the occurrence of the unintended rupture may be a factor against this approach. More studies are needed to compare open and minimally invasive techniques in terms of resectability and cystic rupture rate.

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INTRODUCTION: Foreign bodies ingestion is frequent and can cause several complications. Perforation is rare but can occur in any segment of the gastrointestinal tract. Fish bones are one of the most frequent objects responsible. PRESENTATION OF CASE: A 77-year-old patient resorted to emergency room for severe abdominal pain with 5 days of evolution. A CT scan showed an undefined liquid collection involving a linear image with 25mm, suggestive of a foreign body. On laparotomy an abscess was resected with a fish bone inside. DISCUSSION: Bowel perforation by foreign bodies can mimic other abdominal emergency conditions. Since fish bone ingestion is usually not remembered, diagnosis can be late. Surgery is the treatment of choice and is most commonly performed by laparotomy. CONCLUSION: A low threshold of suspicion along with a good clinical history and radiological studies is extremely important in order to make a correct diagnosis.