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- Surgical Resection of Multiple Small Bowel Neuroendocrine Tumours Using Intraoperative Fluorescence Angiography With Indocyanine Green DyePublication . Rafael, MA; Rocha, R; Oliveira, AM; Rodrigues, C; Carneiro, C; Nunes, V
- Supralevator abscess: New treatment for an uncommon aetiology: Case reportPublication . Aparício, DJ; Leichsenring, C; Sobrinho, C; Pignatelli, N; Geraldes, V; Nunes, VAbstract INTRODUCTION: Supralevator abscess is the least common type of anorectal abscess. Its diagnosis can be hard and treatment difficult. PRESENTATION OF THE CASE: A 48-year-old men was diagnosed in the emergency department with a supralevantor abscess. Under general anaesthesia, the abscess drainage was accomplished after removal of a fish bone, who was perforating the rectum. Due to persistent rectal purulent discharge, a pelvic Magnetic Resonance (MRI) was performed: a supralevator abscess adjacent to the internal obturator muscle and an inter-sphincteric fistulae from the inferior margin of this collection were identified. A Pezzer® drain was placed through the fistula tract. After radiological resolution, under general anaesthesia, the patient was submitted to extraction of the drain and marsupialization of the path left using an ENDO GIA®. At two year follow up he remained asymptomatic. DISCUSSION: Despite of the abscess aetiology, the principles of treatment are the same: good radiological characterization and proper drainage. An adequate radiological characterization is important to avoid iatrogenic creation of a complex fistulae. CONCLUSION: If a supralevator abscess diagnosis is made, fistulae trajectory should be studied. If no clear internal opening is evident, a pelvic MRI should be done followed by drainage of the abscess. After resolution the drain should be taken off and marsupialization with ENDO GIA® should be performed.
- Transmesocolic hernia with sigmoid colon strangulation without surgical history: a series of two case reports.Publication . Aparício, DJ; Leichsenring, C; Pignatelli, N; Germano, A; Ferreira, S; Nunes, VThe incidence of internal hernias is rare (0.2-0.9%). The prevalence of intestinal obstruction for an internal hernia is low (0.5-5%), however if strangulation is present the overall mortality is higher than 50%. There are multiple places where an internal hernia may be localized, with transmesenteric: transmesocolic (8%) and transomental (1-4%) as the rarest. We report a series of two cases (men with 40 years-old and women with 92 years old) of volvulus of colon sigmoid in a strangulated transverse and descendent transmesocolic hernia, with one case associated also to a transomental hernia. Both patients were submitted to a Hartmann procedure and on follow-up remained free of complains. In conclusion, transmesenteric internal hernia should be included as diagnosis hypothesis for intestinal occlusion and if the diagnosis is made, the patient should be submitted to emergency surgery due to high rates of complications, high morbidity and mortality.
- Amputação abdominoperineal extraelevador – RevisãoPublication . Carneiro, C; Rocha, R; Marinho, R; Leichsenring, C; Geraldes, V; Nunes, VDesde a descrição da Excisão Total do Mesorecto (ETM), a taxa de recidiva local da neoplasia do recto submetida a ETM decresceu consideravelmente para valores entre os 5 e 15%. No entanto, no que diz respeito à neoplasia do recto tratada cirurgicamente com amputação abdominoperineal (AAP), esta taxa manteve-se na ordem dos 40%. Os fatores identificados como responsáveis por estes piores resultados oncológicos foram o envolvimento da margem circunferencial de ressecção e a perfuração intraoperatória da peça cirúrgica, que são mais frequentes na amputação abdominoperineal do que na ressecção anterior do recto. Em 2007 Holm et al. descreveram a técnica de extra-levator abdominoperineal excision (ELAPE), com o objetivo de ultrapassar as limitações da AAP em termos de resultados oncológicos. Efectuámos uma revisão sistemática da literatura no que diz respeito à comparação dos outcomes oncológicos e das complicações cirúrgicas associadas à amputação AAP convencional e à ELAPE. O facto de se ter reconhecido os maus resultados oncológicos da AAP convencional e se ter descrito um novo tipo de técnica (a ELAPE) permitiu mudar o foco desta cirurgia, voltando a colocar grande importância no tempo perineal para se obterem taxas de recidiva local semelhantes às descritas para a ETM. A literatura confirma que a ELAPE é uma técnica com muito bons resultados oncológicos. Quanto à taxa de complicações os dados não são conclusivos, parecendo não haver diferença entre a AAP convencional e a ELAPE. A ELAPE é uma técnica promissora que permite melhorar a sobrevida global dos doentes com cancro do recto baixo.
- Unclassified autoimmune pancreatitis mimicking pancreatic cancerPublication . Marinho, R; Alves, A; Pignatelli, N; Nunes, VA 24-year-old black male presented with a 1-week obstructive jaundice and intermittent abdominal pain, with no significant weight loss and an unsuspicious abdominal exam. Blood chemistry showed a cholestatic pattern but a complete immunological and tumoral panel (anti-smooth muscle antibody, anti-mitochondrial antibody, anti-nuclear antibody, anti-neutrophil cytoplasmic antibody, anti-Smith, anti-double-stranded-DNA antibody (anti-dsDNA), complement C3/C4, carcinoembryonic antigen, CA 19-9 and IgG4) were all within normal limits. Abdominal ultrasound revealed dilatation of the intra and extra-hepatic bile ducts. CT scan showed an abnormal dilatation of the distal bile duct but no focal enlargement of the head of the pancreas. Endoscopic ultrasound suggested an inflammatory process but the magnetic resonance cholangio-pancreatography favored a neoplastic obstruction of the distal common bile duct. Fine-needle aspiration cytology was insufficient for definitive diagnosis and the patient underwent major surgery. Follow-up with mild exocrine pancreatic insufficiency treated with enzyme replacement.
- Pancreatic cancer presenting as colonic disease. A rare case reportPublication . Nogueira, S; Pinto, B; Silva, E; Garcia, H; Carneiro, FINTRODUCTION: Pancreatic cancer is the fourth major cause of cancer-related deaths. About 50% of the patients are diagnosed with advanced disease. Metastatic disease to the colon is a very rare entity with only 5 cases described in english literature. CASE PRESENTATION: Male, 60 years-old, presents to a surgical consult with the diagnosis of an adenocarcinoma of the sigmoid colon. The physical exam revealed a periumbilical nodule with suspicious features. The staging CT-scan showed a mass in the tail of the pancreas involving the spleen and left kidney, thickening of the sigmoid colon, multiple mesenteric masses and trabecular changes in the ischium, suggesting metastatic disease. The case was discussed by a multidisciplinary team and it was decided to do a biopsy of the umbilical nodule and review the specimen obtained in colonoscopy. Pathological analysis revealed a metastasis from pancreatic adenocarcinoma. The patient was proposed to start palliative chemotherapy for metastatic pancreatic cancer. After 2 cycles of FOLFOX the patient was admitted in the OR with a perforation of the sigmoid mass. He was submitted to a sigmoidectomy with end colostomy, with discharge at the 5th postoperative day. Pathological analysis of the specimen confirmed the pancreatic origin of the tumor. Patient proceeded with palliative treatment, with death 9 months after the diagnosis. DISCUSSION: Pancreatic metastasis to the colon is a very rare entity. Care should be taken when addressing these patients. CONCLUSION: Although rare, a sigmoid tumor in a patient with known pancreatic adenocarcinoma must raise the suspicion of metastasis.
- Endometriosis: A Rare Cause of Large Bowel Obstruction.Publication . Alexandrino, G; Lourenço, L; Carvalho, R; Sobrinho, C; Horta, D; Reis, JLarge bowel obstruction can result in significant morbidity and mortality, especially in cases of acute complete obstruction. There are many possible causes, the most common in adults being colorectal cancer. Endometriosis is a benign disease, and the most affected extragenital location is the bowel, especially the rectosigmoid junction. However, transmural involvement and acute occlusion are very rare events. We report an exceptional case of acute large bowel obstruction as the initial presentation of endometriosis. The differential diagnosis of colorectal carcinoma may be challenging, and this case emphasizes the need to consider intestinal endometriosis in females at a fertile age presenting with gastrointestinal symptoms and an intestinal mass causing complete large bowel obstruction.
- Urachal Adenocarcinoma: A Case Report with Key Imaging Findings and Radiologic-Pathologic Correlation.Publication . Schmitt, W; Baptista, M; Ferreira, M; Gomes, A; Gernano, AUrachal pathologies are rare and can mimic numerous abdominal and pelvic diseases. Differential diagnosis of urachal anomalies can be narrowed down by proper assessment of lesion location, morphology, imaging findings, patient demographics, and clinical history. We report a case of a 60-year-old male, with a history of unintentional weight loss without associated symptoms, who was diagnosed with locally invasive urachal adenocarcinoma. With this article, we pretend to emphasize urachal adenocarcinoma clinical features along with its key imaging findings with radiologic-pathologic correlation.
- Categorização TIRADS (Thyroid Imaging Reporting and Data System) e Bethesda de Nódulos da Tiróide: Experiência InstitucionalPublication . Germano, A; Schmitt, W; Ribeiro, C; Simões, H; Gasparinho, G; Ferreira, M; Gomes, AIntrodução: As categorizações TIRADS (thyroid imaging reporting and data system) e Bethesda atribuem riscos de malignidade e propõem recomendações a seguir visando uniformizar a interpretação desses exames pelos radiologistas e anatomopatologistas e triar eficazmente nódulos da tiróide para cirurgia ou seguimento. O objectivo do estudo foi avaliar o risco de malignidade das categorias diagnósticas TIRADS e Bethesda nos nódulos da tiróide puncionados na nossa Instituição. Material e Métodos: Foi efectuado um estudo transversal, descritivo e analítico, com avaliação retrospectiva dos dados. Incluíram-se 906 nódulos da tiróide de 842 doentes consecutivos, puncionados entre 01/01/2012 e 31/12/2014. Obteve-se confirmação histológica em 173 nódulos (19,1%). Os diagnósticos citológicos foram categorizados pelo sistema Bethesda. Foram estratificados 743 nódulos nas categorias TIRADS. Estimou-se o risco de malignidade das diferentes categorias TIRADS e Bethesda. Resultados: A percentagem de nódulos malignos entre os operados foi de 26,7 em 2012, 36,9 em 2013 e 55,2 em 2014. Nos estratos TIRADS 2, 3, 4a, 4b e 5 incluíram-se respectivamente 25; 354; 298; 49 e 17 nódulos. Obteve-se uma diferença estatisticamente significativa entre os riscos de malignidade dos nódulos pouco suspeitos (2, 3 e 4a – 5%) e muito suspeitos (4b e 5 – 48,5%), p < 0,001. As percentagens de nódulos nas categorias Bethesda I;II, III, IV, V e VI foram de 9,8; 73,1; 6,1; 5; 3,3 e 28, com riscos de malignidade respectivos de 2 a 15 %; 1 a 8%; 13 a 35%; 24 a 33%; 57 a 77% e 84 a 100%. Obteve-se uma diferença estatisticamente significativa entre os riscos de malignidade dos nódulos não cirúrgicos (I, II e III – 2 a 14%) e cirúrgicos (IV a VI – 49 a 65%), p < 0,001. Conclusão: Na classificação TIRADS, houve prevalência institucional superior à esperada de nódulos malignos na categoria dos provavelmente benignos e inferior à esperada de nódulos malignos nas categorias de elevada suspeição. Na classificação de Bethesda, houve prevalência institucional superior à esperada de nódulos malignos nas categorias benigno/indeterminado. Estas duas técnicas têm sido benéficas na triagem pré-cirúrgica dos pacientes com nódulos da tiróide, facto demonstrado por aumento progressivo da percentagem de nódulos malignos entre os tumores operados de 2012 a 2014.
- Actinomycosis Causing Recurrent Perianal FistulaePublication . Cardoso, M; Carneiro, C; Lourenço, L; Rodrigues, C; Alberto, S; João, A; Rocha, R; Geraldes, V; Costa, A; Reis, J; Nunes, VActinomycosis is a rare but easily curable infection that should be considered in the differential diagnosis of perianal fistulizing disease. We present the case of a 26-year-old woman with complex perianal fistulae, including trans-sphincteric and suprasphincteric fistulous tracts and a rectovaginal fistula, requiring multiple abscess drainages, seton placement, and antibiotic courses, with little improvement. After extensive investigation, Actinomyces spp. was identified in anal cytology. The patient underwent a 6-week course of intravenous penicillin followed by oral amoxicillin, with remarkable improvement. This case illustrates the importance of pursuing less common diagnoses in refractory complex perianal disease, such as actinomycosis.