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Abstract Percutaneous endoscopic necrosectomy is a procedure indicated for managing extensive pancreatic necrosis. Different endoscopic and surgical alternatives have been described for drainage of peripancreatic collections and debridement of necrosis, and minimally invasive approaches have lower complications and mortality rates. We presented the case of a patient with severe pancreatitis associated with pancreatic necrosis extending to both paracolic gutters, who underwent percutaneous endoscopic necrosectomy, after unsuccessful percutaneous and laparoscopic drainage, and a complete resolution of the clinical picture was achieved. Management should consider the clinical condition of the patient, the location of the collections, and the time of evolution of the pancreatitis, and thus choose which intervention will be the most effective, considering also the experience of the medical team and the available resources.

Resumen La necrosectomía endoscópica percutánea es un procedimiento indicado para el manejo de la necrosis pancreática extensa. Se han descrito diferentes alternativas endoscópicas y quirúrgicas para el drenaje de colecciones peripancreáticas y el desbridamiento de la necrosis, y los abordajes mínimamente invasivos tienen menores tasas de complicaciones y mortalidad. Se presenta el caso de un paciente con pancreatitis grave asociada a necrosis pancreática con extensión a ambas goteras parietocólicas, que fue llevado a necrosectomía endoscópica percutánea, luego de drenajes percutáneos y laparoscópicos no exitosos, y se logró una resolución completa del cuadro clínico. Para determinar el manejo, se debe considerar el estado clínico del paciente, la localización de las colecciones y el tiempo de evolución de la pancreatitis, y de este modo elegir qué intervención será la más efectiva, considerando además la experiencia del equipo médico y los recursos disponibles.

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Vertebral artery dissection is a common cause of stroke in young adults without predisposing risk factors for cerebrovascular disease. We describe the case of a 28-year-old patient who presented with an ischemic stroke secondary to a stab wound to the neck that affected the vertebral artery. A physical examination revealed neurological deterioration (Glasgow 8/15), a sutured neck wound, no palpable hematoma, no thrills, and no active bleeding. A computed tomography angiography revealed a left vertebral artery arteriovenous fistula with a component of a pseudoaneurysm, for which a neurointerventional consultation was carried out. Due to neurological compromise, the airway was secured, and because the case involved a posterior fossa infarction with compression of the fourth ventricle and obstructive secondary hydrocephalus, an external ventricular shunt was inserted by neurosurgery. A fistula occlusion was performed with five Axium coils and a vial of Squid 12; the vertebral artery was catheterized, and a craniotomy was performed to manage hydrocephalus with a 12-mm H2O collecting system. The patient was discharged on the tenth day after admission with sequelae of left hemiparesis (predominantly brachial) and no other deficits. There was no hemorrhagic transformation on the control computed tomography scans and no further complications.

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RESUMEN Introducción: Las imágenes diagnósticas son fundamentales para diagnosticar la trombosis de la vena mesentérica y la hernia de Petersen. Objetivo: Describir el tratamiento de una paciente que en angiotomografía presentó aparente trombosis de la vena mesentérica y hernia de Petersen. Caso clínico: Una paciente consultó por dolor abdominal tipo cólico, de predominio en epigastrio, irradiado a región dorsal. Por el cuadro clínico sugestivo de emergencia vascular se solicitó inmediatamente angiotomografía de vasos del tórax y abdomen. Las imágenes revelaron permeabilidad de la arteria mesentérica superior en su origen y en tercio proximal, se aprecia un giro de vasos (signo de remolino) a aproximadamente 7 cm de su origen, con aparente oclusión completa, por trombosis. En el mismo sitio donde se evidenció el giro de vasos, se apreció aparente inicio de trombosis de la vena mesentérica superior. Se realizó procedimiento quirúrgico en el cual se encontró espacio de Petersen y herniación de todo el intestino delgado a través de dicho espacio. La laparotomía evidenció que la paciente no cursó con trombosis, sino que era un efecto dado por la imagen y el hallazgo que se veía era secundario a la hernia de Petersen. Conclusiones: La presencia del signo de remolino en una angiotomografía es muy importante pero no definitiva en el diagnóstico de la hernia de Petersen.

ABSTRACT Introduction: Diagnostic images are essential for the diagnosis of mesenteric vein thrombosis and Petersen's hernia. Objective: To describe the treatment of a patient who presented apparent thrombosis of the mesenteric vein and Petersen's hernia on angiotomography. Clinical case: A patient consulted for colicky abdominal pain predominantly in the epigastrium, radiating to the dorsal region. Due to the clinical picture suggestive of vascular emergency, an angiotomography of the vessels of the thorax and abdomen was immediately requested. The images revealed patency of the superior mesenteric artery at its origin and in the proximal third, appreciating a vessel turn (swirl sign) approximately 7 cm from its origin with apparent complete occlusion due to thrombosis. In the same place where the twisting of the vessels was evident, the initiation of apparent thrombosis of the superior mesenteric vein was appreciated. A surgical procedure was performed in which Petersen's space and herniation of the entire small intestine through this space were found. The laparotomy showed that the patient did not have thrombosis at any time, but that it was an effect given by the image and the finding that was seen was secondary to Petersen's hernia. Conclusions: The presence of the swirl sign on an angiotomography is very important but not definitive in the diagnosis of Petersen's hernia.