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BACKGROUND: To compare the efficacy and safety between emergency hepatectomy (EH) and emergency transarterial embolization (TAE) followed by staged hepatectomy (SH) in the treatment of spontaneous ruptured hepatocellular carcinoma (rHCC). METHODS: Databases (PubMed, EMBASE, Web of science, Cochrane Library, ClinicalTrial.gov, CNKI, Wanfang and VIP) were searched for all relevant comparative studies from January 2000 to October 2020. Odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI) were pooled for dichotomous and continuous variables, respectively. Subgroup analyses based on the kind of embolization were conducted. RevMan 5.3 software was adopted for meta-analysis. RESULTS: Eighteen studies with 871 patients were finally included in this meta-analysis, 448 in EH group and 423 in TAE + SH group. No significant difference was observed in successful hemostasis (P = 0.42), postoperative hospital stay (P = 0.12), complication rate (P = 0.08) between EH and TAE + SH group. However, TAE + SH group was associated with shorter operating time (P < 0.00001), fewer perioperative blood loss (P = 0.007), fewer blood transfusion (P = 0.003), lower in-hospital mortality (P < 0.00001) and higher 1-year survival as well as 3-year survival (P < 0.0001; P = 0.003) compared with EH group. CONCLUSION: Compared with EH, TAE + SH could reduce perioperative operating time, blood loss, blood transfusion, mortality rate and increase the long-term survival rate of the rHCC patients, which may be a better treatment for resectable rHCC.

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Craniopharyngiomas (CPs) are benign tumors that are believed to arise from embryonic remnants of the Rathke pouch epithelium. Herein, we report a case of aseptic meningitis due to spontaneous rupture of multicystic CP, which contained an Ommaya catheter. A 19-year-old boy was admitted to the hospital with a 4-day history of acute severe headache after strenuous physical exercise followed by altered sensorium, fever, and neck stiffness. Cerebrospinal fluid (CSF) analysis revealed marked pleocytosis and elevated protein levels. CSF culture was otherwise negative. Cyst reduction on subsequent imaging confirmed the diagnosis. The patient received intravenous steroid therapy and was discharged asymptomatic. This is a rare evolution of a multicystic CP, which was previously treated with intracystic therapy and had an Ommaya catheter. Clinicians should be aware of spontaneous CP rupture and look actively for the occurrence of cholesterol crystals or elevated CSF levels of cholesterol as well as prompt follow-up imaging.

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Retroperitoneal hemorrhage is a rare and life-threatening clinical presentation that may occur in patients with advanced germ cell tumors, typically after chemotherapy. Rapid clinical suspicion is crucial to offer the best treatment. Surgery is usually recommended but dismal complications may occur. We report on a man with metastatic testicular cancer presenting with massive spontaneous retroperitoneal hemorrhage that had not received previous systemic treatment and was managed without surgical treatment, with good clinical outcome.

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An 83-year-old female patient presented to the Emergency Department with shortness of breath, difficulty swallowing and left-sided chest pain following a vomiting attempt. A rupture in the left lower third of the esophagus, with hydropneumothorax, pneumomediastinum, and subcutaneous emphysema was revealed by chest X-ray, thoracic computed tomography scan, and contrast esophagography. The patient was successfully treated conservatively with closed thoracostomy, intravenous fluids, parenteral nutrition, and broad-spectrum antibiotics coverage. Following the successful conservative treatment, the patient developed a distal esophageal stenosis which was treated with an intra-esophageal self-expanding stent.

Una paciente de 83 años acudió al Servicio de Urgencias con disnea, dificultad para tragar y dolor en el lado izquierdo del pecho tras un intento de vómito. Una rotura en el tercio inferior izquierdo del esófago, con hidroneumotórax, neumomediastino y enfisema subcutáneo fue revelada por radiografía de tórax, tomografía computarizada de tórax y esofagografía con contraste. El paciente fue tratado con éxito de manera conservadora con toracostomía cerrada, líquidos intravenosos, nutrición parenteral y cobertura de antibióticos de amplio espectro. Tras el exitoso tratamiento conservador, el paciente desarrolló una estenosis esofágica distal que fue tratada con un stent autoexpandible intraesofágico.

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Introdução: Este estudo se trata de um relato de caso que tem por objetivo alertar os cirurgiões para uma possível complicação em pós-operatório de cirurgias estéticas longas sob anestesia geral. A Síndrome de Boerhaave é uma doença grave que ameaça a vida do paciente e merece um diagnóstico precoce até 12hs e um tratamento adequado. Relato de caso: A paciente no pós-operatório de cirurgia plástica abdominal e mastopexia apresentou, após anestesia geral, crises de vômito e náuseas. Resultados: Paciente com 58 anos do sexo feminino submetida à dermolipectomia abdominal e mastopexia pela a técnica de pedículo inferior sob raquianestesia, onde após um período de quatro horas do término da cirurgia apresentou vários episódios de vômitos. Após 10 horas do ato cirúrgico apresentou queixa de algia ao deglutir, seguida de algia intensa generalizada, dispneia intensa, sudorese, palidez, PA 90x50mmhg. Com a piora do quadro a paciente foi encaminhada para a unidade de terapia intensiva onde foi entubada. Foram realizados exames laboratoriais, toracocentese e exames radiológicos. Atualmente, a paciente encontra-se com prótese esofágica. Conclusões: Fazendo a correlação com a bibliografia, no caso em tela sugere-se evitar cirurgias prolongadas, principalmente sob anestesia geral onde pode ocorrer a retenção de gás carbônico, que pode levar a crise emética no pós-operatório em pacientes com antecedentes de doença esofagiana e estar atentos aos sintomas, não descartando a possibilidade da ocorrência da Síndrome Boerhaave.

Introduction: The objective of this case report is to alert surgeons to a possible postoperative complication of long cosmetic surgery under general anesthesia. Boerhaave syndrome is a serious life-threatening disease that requires diagnosis within 12 hours and proper treatment. Case report: A 58-year-old female patient presented with vomiting and nausea after abdominoplasty and mastopexy under general anesthesia. Results: The patient underwent dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia. Four hours after the operation, she presented several episodes of vomiting. Ten hours after the operation, she reported painful swallowing followed by generalized severe pain and presented severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure. As the condition worsened, the patient was referred to the intensive care unit where she was intubated and underwent laboratory tests, thoracentesis, and radiological examinations. The patient currently uses an esophageal prosthesis. Conclusions: The literature suggests avoiding prolonged surgery, especially under general anesthesia, because of the risk of carbon dioxide retention, which may lead to postoperative emetic crisis in patients with a history of esophageal disease. It also suggests paying attention to symptoms, not excluding the possibility of Boerhaave syndrome.

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Resumen La ruptura espontánea de un tendón secundario al uso de una quinolona es un efecto adverso poco común, pero que con el paso de los años se ha venido documentado con mayor frecuencia. A pesar de lo anterior, aún no hay estudios clínicos que permitan aclarar su fisiopatología, qué estrategias pueden disminuir el riesgo de desarrollar una ruptura espontánea o a qué dosis de las diferentes quinolonas se aumenta el riesgo de presentar una ruptura espontánea. Adicionalmente, varías guías de práctica clínica incentivan el uso de las quinolonas como primera línea para el manejo de infecciones respiratorias o de vías urinarias sin hacer consideraciones sobre este efecto adverso. Por lo anterior, presentamos a continuación el caso de un paciente de 31 años que posterior al inicio de ciprofloxacina para el manejo de una diarrea aguda presento una ruptura espontánea del tendón del semitendinoso secundario al uso de la quinolona. (Acta Med Colomb 2019; 44: 115-118).

Abstract The spontaneous rupture of a tendon secondary to the use of a quinolone is an uncommon adverse effect, but over the years has been documented more frequently. Despite this, there are still no clini cal studies to clarify its pathophysiology, nor which strategies can reduce the risk of developing a spontaneous rupture or at what dose of the different quinolones the risk of presenting a spontaneous rupture increases. In addition, several clinical practice guidelines encourage the use of quinolones as the first line for the management of respiratory or urinary tract infections without considering this adverse effect. Therefore, the case of a 31 year old patient who after the start of ciprofloxacin for the management of acute diarrhea had spontaneous semitendinosus tendon rupture secondary to the use of quinolone, is presented. (Acta Med Colomb 2019; 44: 115-118).

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Atraumatic splenic rupture, an infrequent surgical emergency, constitutes a life-threatening situation. The lack of a traumatic background makes it difficult to suspect. We present a case of a 45-year-old woman, with history of bariatric surgery, referred to our emergency due to 3 weeks long abdominal and lumbar pain, in shock. Imaging diagnosis of splenic rupture, emergent surgery was performed with atypical findings and good evolution. The bibliographic review, background and surgical findings allowed to postulate causality in this unusual presentation. Despite its low frequency, this pathology involves significant mortality and must be present in the patient in shock in the emergency room.

La rotura esplénica atraumática, una emergencia quirúrgica infrecuente, constituye una situación de riesgo vital. La falta de antecedente traumático dificulta su sospecha. Presentamos el caso de una mujer de 45 años, con antecedente de cirugía bariátrica, remitida a nuestro servicio de urgencias por dolor abdominal y lumbar de 3 semanas, en shock. Con el diagnóstico imagenológico de rotura esplénica, se realizó cirugía emergente, con hallazgos atípicos, y la paciente tuvo una buena evolución. La revisión bibliográfica, los antecedentes y los hallazgos quirúrgicos permitieron postular la causalidad en esta inusual presentación. Pese a su poca frecuencia, esta patología comporta una mortalidad importante y debe tenerse presente ante un paciente en shock en la sala de urgencias.

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Hepatocellular carcinoma (HCC) is the main primary liver malignancy. Its prevalence is increasing and is associated in 90% to cirrhotic patients. Hemoperitoneum secondary to spontaneous rupture of the tumor is an uncommon complication in Latin America and the Western world, being more prevalent in Asian races. However, it is associated to hemodynamic repercussion with high mortality, therefore high level of suspicion and early treatment are required. Regarding the management of the condition, in addition to hemodynamic stabilization, active hemostatic control is recommended over conservative management, transarterial chemoembolization being currently the chosen alternative. We present a series of three clinical cases of patients who debuted with clinical manifestation of hemoperitoneum during the diagnostic process of a HCC.

El carcinoma hepatocelular (CHC) corresponde a la principal neoplasia maligna primaria hepática. Su prevalencia va en aumento y se asocia en 90% a pacientes cirróticos. El hemoperitoneo secundario a rotura espontánea del tumor constituye una complicación infrecuente en Latinoamérica y Occidente, siendo más prevalente en razas asiáticas. Sin embargo, se asocia a repercusión hemodinámica con alta mortalidad, por lo que requiere un alto índice de sospecha y tratamiento oportuno precoz. En cuanto al manejo del cuadro, junto a la estabilización hemodinámica se recomienda un control hemostático activo por sobre manejo conservador, siendo la embolización transarterial la alternativa de elección actualmente. Describimos a continuación una serie de tres casos clínicos de pacientes que debutan con manifestación clínica de hemoperitoneo durante el proceso diagnóstico de un CHC.

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La ruptura espontánea de la vejiga se considera una urgencia urológica que requiere un alto índice de sospecha para realizar el diagnóstico y su tratamiento puede llegar a tener gran complejidad. Se reporta un caso de una paciente de 54 años, con antecedente de cáncer de cuello uterino tratado con radioterapia en 1993 y un sarcoma pleomorfo en la región lumbar-sacra manejada con cirugía, quimioterapia y radioterapia en el 2007. Consultó al servicio de urgencias por un cuadro de dolor progresivo en el hipogastrio, emesis e incontinencia de orina mixta. En la tomografía abdominal y pélvica hubo evidencia de extravasación del medio de contraste en la pared posterior de vejiga. Se practicó una laparotomía exploratoria y sutura vesical. La paciente presentó una adecuada evolución y en el seguimiento la tomografía pélvica fue normal.

Spontaneous rupture of the bladder is considered a urological emergency requiring a high index of suspicion for its diagnosis, and treatment can have a high degree of complexity. A case is presented of a 54 year-old patient with a history of cervical cancer treated with radiotherapy in 1993, and pleomorphic sarcoma in the lumbar and sacral region that received management with surgery, chemotherapy and radiotherapy in 2007. She consulted in the emergency room with symptoms of progressive lower abdomen pain, emesis, and mixed urinary incontinence. The abdominal and pelvic tomography showed no evidence of extravasation of the contrast medium in the posterior wall of the bladder. An exploratory laparotomy and bladder suture was performed. The patient showed adequate progress and the follow-up pelvic scan was normal.

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Introducción. La regurgitación valvular aórtica tiene diversos mecanismos, formas de presentación y etiología. La causa de ruptura espontánea es muy rara, la literatura se limita a casos aislados. Objetivo. Evaluar la correlación clínico-patológica de la ruptura o fenestración o eversión valvular aórtica espontánea y sus formas de presentación. Materiales. Estudio observacional, retrospectivo, de 9 pacientes, con aparición de nuevo soplo diastólico, 7 hombres de 28, 36, 42, 53, 56 y dos de 58 años, 2 mujeres de 66 y 75 años; quienes ingresaron por mayor deterioro de su clase funcional (CF) según New York Heart Association (NYHA). Resultados. La forma de presentación fue con mayor deterioro de la CF en los pacientes más jóvenes (CF III/ lV NYHA). El eco-Doppler cardíaco mostró: a) leve a moderada degeneración mixomatosa de la válvula aórtica (VAo), trivalva en 8 pacientes y bicúspide en uno. b) La cúspide aórtica evertida fue la valva coronariana derecha en 8 pacientes y en un paciente, masculino, la sigmoidea izquierda; en todos con ruptura y amplia protrusión o fenestración en tracto de salida del ventrículo izquierdo. c) Severa insuficiencia valvular aórtica (IAo). d) Dilatación de cavidad izquierda y moderada a severa disfunción sistólica. e) Válvula mitral con leve degeneración mixomatosa sin prolapso. f) Hipertensión pulmonar moderada. f) No se identificaron vegetaciones valvulares y no hubo signos de endocarditis aguda o curada en todos los pacientes. Se derivó a cirugía al 100% de los pacientes, 1 óbito post quirúrgico inmediato (11,1%), 2 óbitos en prequirúrgico (22,2%) y 3 pacientes con cirugías exitosas (33,3%), se desconoce evolución del resto. Conclusiones. 1) La patogénesis de la afección puede ser mixomatosis de una cúspide y del anillo aórtico. En el 88,8% de los casos la ruptura correspondió a la valva coronariana derecha. 2) La fenestración extensa de una cúspide valvular aórtica, de causa degenerativa puede causar IAo moderada-severa y disfunción sistólica del ventrículo izquierdo después de la ruptura de una cúspide valvular. 3) Dicha ruptura no infecciosa y no traumática de una VAo puede resultar además en una IAo aguda severa, particularmente, en hombres con hipertensión arterial crónica.

Antecedents. Aortic valvular regurgitation has diverse mechanisms, forms of presentation and etiology. The cause like spontaneous rupture is very rare and literature is limited isolated reports of cases. Objective. To evaluate the clinic pathological correlation of rupture or fenestration or eversion spontaneous aortic valve and its presentation. Materials. Observational, retrospective study of 9 patients with new onset diastolic murmur, 7 men of 28, 36, 42, 53, 56 and two of 58 years and 2 women of 66 and 75 years; who they were admitted for further deterioration of the New York Heart Association functional class (NYHA FC). Results. The mode of presentation was to further deterioration of the FC in younger patients (NYHA FC III/IV). Doppler echocardiography color showed: a) mild to moderate myxomatous degeneration of the aortic valve, tricuspid in 8 patients and one bicuspid; b) the everted aortic cusp was the right coronary cusp in 8 patients and in one patient, male, left sigmoid; all with break and wide fenestration protrusion or outflow tract of the left ventricle; c) severe aortic regurgitation; d) dilated left cavity and moderate to severe systolic dysfunction; e) mitral valve myxomatous degeneration with mild without prolapse; f) moderate pulmonary hypertension; f) no valvular vegetations were identified and there were no signs of acute or cured endocarditis in all patients. It was referred to surgery 100% of patients 1 immediate post operative death (11.1%), 2 deaths in pre-surgical (22.2%) and 3 patients with successful surgeries (33.3%), evolution is unknown the other patients. Conclusions. 1) The pathogenesis of this one affection would be the mixomatosis of cusp and the ring to valvular aortic. In 88.8% of cases he corresponded to rupture the right coronary cusp. 2) A fenestrated cusp in extensive form with an expanded aortic ring of degenerative cause can cause chronic insufficiency or sudden deterioration after the rupture of a one cusp valvular. 3) No infectious and no traumatic rupture of cord-like aortic valve structures may result in severe acute aortic regurgitation. Particularly in men with chronic hypertension.

Introdução. A regurgitação valvular aórtica tem diversos mecanismos, formas de apresentação e etiologia. A causa da ruptura espontânea é muito rara, a literatura é limitada á casos isolados. Objetivo. Avaliar a correlação clínico-patológica da ruptura ou fenestração ou eversão da valva aórtica espontânea e sua apresentação. Materiais. Estudo observacional, retrospectivo de 9 pacientes com aparição de novo sopro diastólico, 7 homens de 28, 36, 42, 53, 56 e dois de 58 anos e 2 mulheres de 66 e 75 anos, com insuficiência aórtica grave foram admitidos à maior deterioração da classe funcional da New York Heart Association (CF-NYHA). Resultados. O modo de apresentação foi com maior deterioração da CF-NYHA em os pacientes mais jovens (NYHA CF III/IV). O ecocardiograma com Doppler colorido mostrou: a) leve a moderada degeneração mixomatosa da valva aórtica, tricúspide em 8 pacientes e bicúspide em um; b) a cúspide aórtica fenestrada foi a cúspide coronária direita em 8 pacientes e em um paciente, do sexo masculino, a cúspide esquerda; em todos com ruptura e ampla protrusão ou via de saída do ventrículo esquerdo; c) regurgitação aórtica grave; d) dilatada cavidade esquerda e moderada a grave disfunção sistólica; e) válvula mitral com leve degeneração mixomatosa sem prolapso; f) hipertensão pulmonar moderada; f) não foram identificadas vegetações valvares e não houve sinais de endocardite aguda ou curada em todos os pacientes. A intervenção cirúrgica foi recomendada em todos os casos, dois pacientes morreram no pós-operatório e um paciente morreu no pré-operatório. Conclusões. 1) A patogênese desta doença pode ser mixomatose de uma cúspide e do anel valvar aórtico. Em 88,8% dos casos, a ruptura correspondeu à cúspide coronariana direita. 2) A fenestração extensa de uma cúspide valvar aórtica de causa degenerativa pode causar insuficiência aórtica moderada a grave e disfunção sistólica do ventrículo esquerdo após da ruptura de uma cúspide. 3) Nesta ruptura não infecciosa e não traumática de uma valva aórtica pode resultar na insuficiência aórtica aguda grave. Particularmente em homens com hipertensão arterial crônica.

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Epithelial ovarian tumors are the most common malignant ovarian neoplasms and, in most cases, eventual rupture of such tumors is associated with a surgical procedure. The authors report the case of a 54-year-old woman who presented with spontaneous rupture of ovarian cystadenocarcinoma documented by computed tomography, both before and after the event. In such cases, a post-rupture staging tends to be less favorable, compromising the prognosis.

Os tumores epiteliais correspondem à maioria das neoplasias ovarianas, sendo que eventuais rupturas estão mais relacionadas ao ato cirúrgico. Relatamos um caso de cistoadenocarcinoma ovariano em uma paciente de 54 anos com documentação tomográfica pré- e pós-ruptura espontânea. O estadiamento tumoral pós-ruptura tende a ser menos favorável, comprometendo o prognóstico desses pacientes.

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AbstractEpithelial ovarian tumors are the most common malignant ovarian neoplasms and, in most cases, eventual rupture of such tumors is associated with a surgical procedure. The authors report the case of a 54-year-old woman who presented with spontaneous rupture of ovarian cystadenocarcinoma documented by computed tomography, both before and after the event. In such cases, a post-rupture staging tends to be less favorable, compromising the prognosis.

ResumoOs tumores epiteliais correspondem à maioria das neoplasias ovarianas, sendo que eventuais rupturas estão mais relacionadas ao ato cirúrgico. Relatamos um caso de cistoadenocarcinoma ovariano em uma paciente de 54 anos com documentação tomográfica pré- e pós-ruptura espontânea. O estadiamento tumoral pós-ruptura tende a ser menos favorável, comprometendo o prognóstico desses pacientes.

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La rotura espontanea de vasos uterinos es una rara causa de abdomen agudo hemorrágico durante el embarazo y una complicación potencialmente mortal. Las manifestaciones clínicas son: dolor abdominal súbito, shock hipovolémico y caída de hematocrito. Objetivos: Presentación de causa infrecuente de abdomen agudo hemorrágico. Reporte de Caso: Se presenta un caso de una mujer de 36 años primigesta, con embarazo de 27 semanas, con abdomen agudo, sin antecedentes traumáticos y signos de shock hipovolémico. Ecografía abdominal con líquido libre en cavidad. En laparotomíaexploradora se halla laceración de vena uterina derecha, se realiza hemostasia directa y cesárea de urgencia por bradicardia fetal severa. Discusión: Debe realizarse un correcto diagnóstico diferencial dado que el tratamiento de la rotura espontanea de los vasos uterinos es el manejo urgente del shock hipovolémico y la intervención quirúrgica a la brevedad...

Spontaneous rupture of uterine vessels is a rarecause of acute abdomen bleeding during pregnancy and apotentially fatal complication.Clinical manifestations include sudden abdominal pain,hypovolemic shock and fall of hematocrit.Objectives: Introducing rare cause of acute abdomen bleeding.Case Report: We presents case of a woman aged 36 with 27weeks pregnancy (first one), acute abdomen, without traumatichistory WITH signs of hypovolemic shock. Abdominal ultrasoundwith free fluid in the cavity. At laparotomy we found laceration ofthe right uterine vein, performing direct hemostasis andemergency cesarean for severe fetal bradycardia.Discussion: We have to make sure of doing a correct differentialdiagnosis because the treatment of spontaneous rupture of theuterine vessels is urgent for management of hypovolemic shockand surgery should be performed promptly...

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Spontaneous perforation of gallbladder is a severe and infrequent complication of acute cholecystitis that requires early and accurate diagnosis. Concomitant development of intrahepatic collections is rarely observed in such cases. The present report emphasizes the relevance of imaging studies in this setting, describing the typical sonographic and tomographic findings for the diagnosis of such condition.

A perfuração espontânea da vesícula biliar é uma complicação grave e pouco frequente da colecistite aguda, que exige diagnóstico rápido e preciso; a formação concomitante de coleções intra-hepáticas nesses casos é rara. O presente relato enfatiza a importância dos exames de imagem nesse contexto, demonstrando sinais ultrassonográficos e tomográficos típicos para o diagnóstico.

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Hemangiomas hepáticos gigantes são incomuns no fígado. Sexo feminino e uso prolongado de anticoncepcionais orais têm sido associados com alto risco de desenvolvimento de hemangiomas. Ruptura de hemangioma é extremamente rara, grave e requer intervenção cirúrgica. Embolização arterial transcateter pode ser utilizada antes da cirurgia para controle do sangramento e redução do volume do hemangioma, facilitando a hepatectomia. Relatamos um caso de mulher de meia-idade em uso crônico de anticoncepcionais orais, com ruptura espontânea de duplo hemangioma hepático gigante.

Giant hepatic hemangiomas are uncommon in the liver. Female and prolonged use of oral contraceptives have been associated with a high risk of developing hemangiomas. Rupture of hemangioma is extremely rare, serious and requires surgical intervention. Transcatheter arterial embolization may be used before surgery to control bleeding and reducing the volume of the hemangioma, facilitating hepatectomy. We report a case of a middle-aged woman with chronic use of oral contraceptives and spontaneous rupture of double giant hepatic hemangioma.

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O hepatocarcinoma (CHC) é uma das neoplasias mais comuns em todo o mundo. A ruptura espontânea é rara nos países ocidentais. Neste relato descreve-se o caso de paciente do gênero masculino, 54 anos, que se apresentou ao pronto-socorro com sinais de abdome agudo e choque. A cirurgia exploradora diagnosticou hemoperitônio volumoso secundário à ruptura espontânea de um tumor hepático. A biópsia confirmou o diagnóstico de hepatocarcinoma. Sorologia para hepatite C foi positiva. O presente caso ilustra a progressão assintomática da cirrose até o diagnóstico tardio de CHC, quando medidas terapêuticas curativas já não mais podem ser implantadas.

Hepatocellular carcinoma is one of the most common neoplasias worldwide, but spontaneous rupture is rare in Western countries. This case report describes a 54-year-old male patient that came to ambulance station with symptoms of concussion and acute abdomen. An exploratory surgery diagnosed large hemoperitoneum secondary to spontaneous rupture of a hepatocellular tumor. Biopsy confirmed the diagnosis of hapatocellular carcinoma. Serological test of hepatitis C was positive. The case report illustrates the asymptomatic progression of cirrhosis until late diagnosis of hepatocellular carcinoma, when no therapeutic and curative care can be provided.

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INTRODUCCIÓN: El neumotórax espontáneo (NEP) es la presencia de aire en la pleura sin etiología identificable. Después de un primer episodio 30 por ciento recidiva, aún sin consenso del manejo de ambos. Postulamos relación entre datos del paciente consultante por NEP con la recidiva de un neumotórax espontáneo primario primer episodio (NEPPE). OBJETIVO: Identificar características del paciente recidivado del NEPPE (RNEP) versus el paciente sin recidiva. MATERIAL Y MÉTODO: Estudio de casos y controles. Se analizaron datos de pacientes atendidos en el Servicio de Cirugía del Hospital Gustavo Fricke entre Enero de 2006 y Junio de 2010. Nuestro n=41 con 17 casos (16 hombres, mediana edad 21 años) de RNEP y 24 controles (23 hombres, mediana edad 20,5 años) para NEPPE no recidivados. Se describieron datos y se analizó asociación entre variables en función de los casos y controles a través de Odds Ratio. RESULTADOS: Se encontró que los pacientes que debutaron su NEPPE en la temporada de otoño tenían mayor recidiva que las otras temporadas con OR de 7,8 (IC 95 por ciento: 1,40-53,85). El tabaco no muestra asociación con OR de 0,297 (IC 95 por ciento:0,062-1,315). DISCUSIÓN: No se encontró significancia estadística entre otras variables y la recidiva o no del NEPPE. Concluimos que debutar un NEPPE en otoño predispone a RNEP, aunque faltarían estudios con una muestra mayor para establecer conductas. A pesar de que algunos estudios dan importancia al tabaco en la recidiva del NEPPE, no encontramos igual asociación que puede explicarse por la poca gente de nuestro grupo que fumaba.

INTRODUCTION: Spontaneous pneumotorax (SP) is defined as the presence of air into the pleura without recognizable cause. After a first episode of SP, 30 percent of them recur, without consensus about their management. We postulated a relationship between anamnesis and recurrence of a first episode of SP. OBJETIVE: Our aim was to identify characteristics of patients who recurred compared with patients without recurrence. MATERIAL AND METHOD: We analyzed information of patients attended treated in Surgery Service of Gustavo Fricke Hospital between January of 2006 and Juny of 2010. Our patients were 41, with17 patients (16 male, average age of 21) with recurred SP and 24 controls (23 male, average age of 20.5) with non recurred SP. Data were described and relationship between variables in cases and control patients using Odds Ratio was analyzed. RESULTS: Patients with their first episode of SP occurred in autumn were more likely to recur with an OR of 7,8 (CI 95 percent: 1.40-53.85). Smoking did not show relationship with recurrence (OR of 0.297, CI 95 percent 0.062-1.315). Other variables were not statistically significant for recurrence or not of first episode of SP. DISCUSSION: Although more studies with a larger amount of patients are needed to define a proper management, we concluded that a first episode of SP occurred in autumn predisposes a recurrence of this disease. In addition, we did not found relationship between smoking and SP recurrence, maybe because the low prevalence of smoking in our sample, in contrast with some studies which postulate it as a risk factor.

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O pseudocisto de pâncreas é caracterizado como uma coleção fluida rica em enzimas pancreáticas circundada por tecido de fibrose e granulação, sendo mais comum nos casos de pancreatite crônica e, também, na etiologia alcóolica da doença. Sua indicação cirúrgica se baseia nos casos assintomáticos que não tendem à regressão e nas suas complicações. Entre elas, bastante rara, destaca-se a ruptura espontânea do pseudocisto de maneira livre para cavidade abdominal. Relatamos aqui um caso de ruptura espontânea para cavidade abdominal de pseudocisto pancreático com quadro clínico de abdome agudo com pneumoperitônio no raio-x, que foi tratado com drenagem externa do mesmo para a parede abdominal. Apesar de cada vez mais consagrado o tratamento dessa patologia por via endoscópica ou percutânea, relatamos aqui um raro caso aonde a conduta cirúrgica se tornou imperativa, sendo bastante útil para os cirurgiões.

Pseudocyst of the pancreas is characterized as a fluid collection rich in pancreatic enzymes surrounded by fibrotic tissue and granulation, being more common in cases of chronic pancreatitis. Its surgical indication is based on the asymptomatic cases that do not tend to regression and on its complications. Among them, though very rare, there is spontaneous rupture of the pseudocyst freely into the abdominal cavity. Here we report a case of spontaneous rupture of pancreatic pseudocyst into the abdominal cavity with a clinical picture of acute abdomen with radiologic pneumoperitoneum, which was treated with external drainage to the abdominal wall. Although treatment through endoscopic or percutaneous route is increasingly well established, here we report a rare case in which the surgical procedure became imperative.

Assuntos

RESUMO

Aneurysms of the sinus of Valsalva (SV) and the atrial septum are a rare association. We report the case of a 28-year-old woman, who was admitted to our department complaining of progressive dyspnea of 10 days of evolution, five hours previous to her admission to the hospital; she presented sudden oppressive anterior chest pain, accompanied by palpitations. The presence of rupture of the right SV to the right atrium was clinically confirmed, by echocardiography and hemodynamic studies. In addition, an associated atrial septal aneurysm was found. She underwent surgical correction through sinusplasty without requiring aortic valve replacement. The patient presented persistent postoperative atrioventricular block, which required a permanent pacemaker. Clinical evolution was satisfactory. To our knowledge, this case is a rare combination of two isolated malformations, without previous events that could explain the rupture of the right SV.

Los aneurismas del seno de Valsalva y del septum interauricular son una asociación rara. Informamos el caso de una mujer de 28 años de edad con un cuadro de disnea progresiva en los últimos 10 días, al cual se agregó dolor precordial opresivo, cinco horas previas a su ingreso. Se comprobó clínicamente, por ecocardiografía y hemodinamia la presencia de ruptura del seno de Valsalva derecho hacia el atrio derecho. Un hallazgo interesante fue la presencia de un aneurisma del septum interauricular asociado. La paciente fue sometida a corrección quirúrgica con plastía del seno de Valsalva, sin requerir reemplazo valvular aórtico. En el postoperatorio presentó bloqueo aurículo-ventricular persistente, requiriendo implante de marcapaso definitivo. Su evolución fue satisfactoria. Este es un caso de una rara asociación de dos malformaciones aisladas.

Assuntos

RESUMO

Hepatic hemangiomas are congenital vascular malformations, considered the most common benign mesenchymal hepatic tumors, composed of masses of blood vessels that are atypical or irregular in arrangement and size. Hepatic hemangiomas can be divided into two major groups: capillary hemangiomas and cavernous hemangiomas These tumors most frequently affect females (80%) and adults in their fourth and fifth decades of life. Most cases are asymptomatic although a few patients may present with a wide variety of clinical symptoms, with spontaneous or traumatic rupture being the most severe complication. In cases of spontaneous rupture, clinical manifestations consist of sudden abdominal pain, and anemia secondary to a haemoperitoneum. Disseminated intravascular coagulopathy can also occur. Haemodynamic instability and signs of hypovolemic shock appear in about one third of cases. As the size of the hemangioma increases, so does the chance of rupture. Imaging studies used in the diagnosis of hepatic hemangiomas include ultrasonography, dynamic contrast-enchanced computed tomography scanning, magnetic resonance imaging, hepatic arteriography, digital subtraction angiography, and nuclear medicine studies. In most cases hepatic hemangiomas are asymptomatic and should be followed up by means of periodic radiological examination. Surgery should be restricted to specific situations. Absolute indications for surgery are spontaneous or traumatic rupture with hemoperitoneum, intratumoral bleeding and consumptive coagulopathy (Kassabach-Merrit syndrome). In a patient presenting with acute abdominal pain due to unknown abdominal disease, spontaneous rupture of a hepatic tumor such as a hemangioma should be considered as a rare differential diagnosis.