RESUMO

Abdominal wall (AW) hernias are a common problem faced by general surgeons. With an essentially clinical diagnosis, abdominal hernias have been considered a simple problem to be repaired. However, long-term follow-up of patients has shown disappointing results, both in terms of complications and recurrence. In this context, preoperative planning with control of comorbidities and full knowledge of the hernia and its anatomical relationships with the AW has gained increasing attention. Computed tomography (CT) appears to be the best option to determine the precise size and location of abdominal hernias, presence of rectus diastase and/or associated muscle atrophy, as well as the proportion of the hernia in relation to the AW itself. This information might help the surgeon to choose the best surgical technique (open vs MIS), positioning and fixation of the meshes, and eventual need for application of botulinum toxin, preoperative pneumoperitoneum or component separation techniques. Despite the relevance of the findings, they are rarely described in CT scans as radiologists are not used to report findings of the AW as well as to know what information is really needed. For these reasons, we gathered a group of surgeons and radiologists to establish which information about the AW is important in a CT. Finally, a structured report is proposed to facilitate the description of the findings and their interpretation.

Assuntos

RESUMO

ABSTRACT Abdominal wall (AW) hernias are a common problem faced by general surgeons. With an essentially clinical diagnosis, abdominal hernias have been considered a simple problem to be repaired. However, long-term follow-up of patients has shown disappointing results, both in terms of complications and recurrence. In this context, preoperative planning with control of comorbidities and full knowledge of the hernia and its anatomical relationships with the AW has gained increasing attention. Computed tomography (CT) appears to be the best option to determine the precise size and location of abdominal hernias, presence of rectus diastase and/or associated muscle atrophy, as well as the proportion of the hernia in relation to the AW itself. This information might help the surgeon to choose the best surgical technique (open vs MIS), positioning and fixation of the meshes, and eventual need for application of botulinum toxin, preoperative pneumoperitoneum or component separation techniques. Despite the relevance of the findings, they are rarely described in CT scans as radiologists are not used to report findings of the AW as well as to know what information is really needed. For these reasons, we gathered a group of surgeons and radiologists to establish which information about the AW is important in a CT. Finally, a structured report is proposed to facilitate the description of the findings and their interpretation.

RESUMO Hérnias da parede abdominal são um problema bastante comum enfrentado pelo cirurgiões gerais. De diagnóstico essencialmente clínico, as hérnias abdominais durante muito tempo têm sido consideradas um problema de simples reparo. Entretanto, o acompanhamento de longo prazo dos pacientes têm demonstrado resultados desapontadores, tanto em termos de complicações quanto risco de recidiva da hérnia. Neste contexto, o planejamento pré-operatório com controle de comorbidades e pleno conhecimento da hérnia e suas relações anatômicas com a parede abdominal têm ganho cada vez mais atenção. A tomografia de abdome parece ser a melhor opção para determinar o tamanho e localização precisos das hérnias abdominais, presença de diastase de músculo reto e/ou atrofia da parede associada, assim como proporção da hérnia em relação a parede abdominal. Essas informações podem auxiliar o cirurgião na escolha da melhor técnica cirúrgica (aberta vs. MIS), posicionamento e fixação das telas, e eventual necessidade de aplicação de toxina botulínica, pneumoperitônio pré-operatório ou técnicas de separação de componentes. Apesar da relevância dos achados, eles são raramente descritos em exames de tomografia uma vez que os radiologistas não estão acostumados a olhar para a parede abdominal assim como não sabem quais as informações são realmente necessárias. Por estes motivos, nós reunimos um grupo de cirurgiões e radiologistas visando estabelecer quais são as informações da parede abdominal mais importantes em um exame de tomografia assim como propor um laudo estruturado para facilitar a descrição dos achados e sua interpretação.

RESUMO

Fetus in fetu (FIF) is a rare congenital anomaly in which a malformed fetus is incorporated within the body of its twin. It was first described in the late 18th century and has an incidence of 1:500,000 live births. In most cases, the diagnosis is made in infants or young adults. To date, the oldest patient reported in the literature was 47 years old. We describe the case of a 65-year-old patient with FIF, now the oldest reported in the literature. Our patient meets all the diagnostic criteria for FIF, including the presence of a limb in advanced formation inside the lesion. The treatment was surgical excision. FIF should be considered in the differential diagnosis of abdominal masses, typically recognized in infancy. Symptoms arise from mass effects. Surgical resection should be performed due to the potential for malignant transformation.

Assuntos

RESUMO

Malignant melanoma is the 19th leading cause of cancer worldwide. It is an aggressive neoplastic disease in which pathophysiological understanding and management has been in constant evolution in recent decades. The primary site is the skin, uvea and mucous membranes and has the capacity to metastasize to any organ. There are few reports of primary or secondary involvement of the biliary tract. We present the case of a 73-year-old woman with a bile duct lesion suggestive of cholangiocarcinoma and a final diagnosis of a single melanoma metastasis. Surgical treatment was performed due to oligometastatic stage IV melanoma with possibility of R0 resection followed by immune checkpoint therapy.

RESUMO

Endometriosis is a benign gynecologic disease characterized by the presence of endometrial tissue outside the uterine cavity. The complexity of the disease results from its multiple clinical presentations, the multifocal pattern of distribution of the lesions, the presence of extra pelvic sites of the disease (mainly affecting the urinary and the intestinal tracts), and the difficulty in the preoperative diagnosis (by means of imaging studies) and in the surgical treatment. The preoperative mapping of the lesions, either by ultrasound or by magnetic resonance imaging, allows for an adequate surgical planning and a better preoperative patient counseling, especially in those women with deep infiltrating endometriosis affecting the bowel. Also, the choice of the surgical team that is going to perform the procedure may be based on the preoperative workup. In this paper, we highlight the important findings that should be described in the imaging examination reports for the preoperative workup of patients with deep infiltrating endometriosis of the intestine.

RESUMO

Synovial chondromatosis is a benign condition characterized by synovial proliferation and metaplasia, with development of cartilaginous or osteocartilaginous nodules within a joint, bursa or tendon sheath. In the shoulder, synovial osteochondromatosis may occur within the glenohumeral joint and its recesses (including the tendon sheath of the biceps long head), and in the subacromial-deltoid bursa. Such condition can be identified either by radiography, ultrasonography or magnetic resonance imaging, showing typical features according to each method. Radiography commonly shows ring-shaped calcified cartilages and periarticular soft tissues swelling with erosion of joint margins. Ultrasonography demonstrates hypoechogenic cartilaginous nodules with progressive increase in echogenicity as they become calcified, with development of posterior acoustic shadow in case of ossification. Besides identifying cartilaginous nodules, magnetic resonance imaging can also demonstrate the degree of synovial proliferation. The present study is aimed at describing the imaging findings of this entity in the shoulder.

Osteocondromatose sinovial é uma afecção benigna caracterizada por proliferação e metaplasia sinovial, com formação de nódulos cartilaginosos ou osteocartilaginosos no interior de uma articulação, bursa ou bainha tendinosa. A osteocondromatose sinovial no ombro pode ocorrer no interior da articulação glenoumeral e seus recessos (incluindo a bainha do tendão da cabeça longa do bíceps) e na bursa subacrômio-deltoidiana. Esta doença pode ser identificada por radiografia, ultrassom ou ressonância magnética, apresentando aspectos característicos em cada um destes métodos. Na radiografia comumente encontramos calcificações anelares do tipo cartilaginoso e aumento de volume das partes moles periarticulares com erosões das margens articulares. No ultrassom os nódulos cartilaginosos apresentam-se hipoecogênicos, e quando calcificados aumentam progressivamente a sua ecogenicidade, até a formação de sombra acústica posterior quando ossificados. A ressonância magnética, além de identificar os nódulos cartilaginosos, também é capaz de mostrar o grau de proliferação sinovial. O objetivo deste trabalho é demonstrar os aspectos de imagem desta doença no ombro.

RESUMO

PURPOSE: To correlate preoperative serum cancer antigen 125 (Ca-125) levels and laparoscopic findings in women with pelvic pain symptoms suggestive of endometriosis. METHODS: A retrospective study was conducted including all women with pelvic pain symptoms suspected for endometriosis operated by laparoscopy from January 2010 to March 2013. Patients were divided into 2 groups according to preoperative Ca-125 level (<35 U/mL and ≥ 35 U/mL). Subsequently, patients with ovarian endometriomas were excluded and a further analysis was conducted again according to the preoperative Ca-125 level. The following parameters were compared between groups: presence of ovarian endometrioma, presence and number of deep infiltrating endometriosis (DIE) lesions and American Society for Reproductive Medicine score. The statistical analysis was performed with Statistica version 8.0, using the Fisher exact test, Student's t-test and Mann-Whitney test, when needed. A p value of <0.05 was considered to be statistically significant. RESULTS: During the study period, a total of 350 women were submitted to laparoscopic treatment of endometriosis. One hundred thirty patients (37.1%) had Ca-125 ≥ 35 U/mL and 220 (62.9%) had Ca-12<35 U/mL. The presence of ovarian endometriomas (47.7 versus 15.9%), DIE lesions (99.6 versus 78.6%) and intestinal DIE lesions (60 versus 30.9%) was more frequent, and the AFSr score was higher (34 versus 6) in the former group. In the second analysis, excluding the patients with ovarian endometriomas (≥ 35 U/mL=68 patients and <35 U/mL=185 patients), similar results were obtained. The presence of DIE lesions (91.2 versus 76.2%), intestinal DIE lesions (63.2 versus 25.4%), bladder DIE lesions (20.6 versus 4.8%) and ureteral DIE lesions (7.3 versus 1.6%) was more frequent, and the AFSr score was higher (10 versus 6) in the Ca-125 ≥ 35 U/mL group. CONCLUSIONS: Investigation for DIE is mandatory in women with pelvic pain symptoms suggestive of endometriosis with a preoperative Ca-125 level ≥ 35 U/mL, especially when an ovarian endometrioma is not present.

Assuntos

RESUMO

Herniation of the pelvic structures into the uterine cavity (appendix vermiformis, small bowel, omentum, or fallopian tube) may occur after uterine perforation. In this paper, we describe one case of intrauterine fallopian tube incarceration treated by means of laparoscopic surgery.

RESUMO

OBJETIVO: Correlacionar os níveis séricos pré-operatórios do antígeno do câncer 125 (Ca-125) e os achados laparoscópicos em mulheres com sintomas dolorosos sugestivos de endometriose. MÉTODOS:Um estudo retrospectivo foi realizado incluindo todas as mulheres com sintomas de dor pélvica suspeitos para endometriose operadas por laparoscopia no período de janeiro de 2010 a março de 2013. As pacientes foram divididas em 2 grupos de acordo com a dosagem de Ca-125 (<35 U/mL e >35 U/mL). Subsequentemente, as pacientes com endometrioma ovariano foram excluídas e uma análise adicional foi conduzida novamente de acordo com os níveis do Ca-125. Os seguintes parâmetros foram comparados entre os grupos: presença de endometrioma, presença e número de lesões de endometriose profunda infiltrativa (EPI) e escore da American Society for Reproductive Medicine. A análise estatística foi realizada com o programa Statistica versão 8.0, usando o teste exato de Fisher, o teste t de Student e o teste Mann-Whitney, quando necessário. Os valores p<0,05 foram considerados estatisticamente significativos. RESULTADOS: Durante o período de estudo, um total de 350 mulheres foram submetidas a tratamento laparoscópico de endometriose. Cento e trinta pacientes (37,1%) apresentaram Ca-125 >35 U mL e 220 (62,9%) apresentaram Ca-125 <35 U/mL. A presença de endometrioma ovariano (47,7 versus 15,9%), lesões de EPI (99,6 versus 78,6%) e lesões de EPI intestinal (60 versus 30,9%) foi mais frequente, e o escore da AFSr foi maior (34 versus 6) no primeiro grupo. Na segunda análise, excluindo as pacientes com endometrioma ovariano (>35 U/mL=68 pacientes e <35 U/mL=185 pacientes), resultados semelhantes foram obtidos. A presença de lesões de EPI (91,2 versus 76,2%), lesões de EPI intestinal (63,2 versus 25,4%), lesões de EPI de bexiga (20,6 versus 4,8%) e lesões de EPI ureteral (7,3 versus 1,6%) foi mais frequente, e o escore da AFSr foi maior (10 versus 6) no grupo Ca-125>35 U/mL. CONCLUSÕES: Em mulheres com sintomas dolorosos pélvicos suspeitos para endometriose com dosagem pré-operatória de Ca-125 >35 U/mL, a investigação de EPI é mandatória, especialmente quando não se identifica endometrioma ovariano em exames de imagem.

PURPOSE: To correlate preoperative serum cancer antigen 125 (Ca-125) levels and laparoscopic findings in women with pelvic pain symptoms suggestive of endometriosis. METHODS: A retrospective study was conducted including all women with pelvic pain symptoms suspected for endometriosis operated by laparoscopy from January 2010 to March 2013. Patients were divided into 2 groups according to preoperative Ca-125 level (<35 U/mL and >35 U/mL). Subsequently, patients with ovarian endometriomas were excluded and a further analysis was conducted again according to the preoperative Ca-125 level. The following parameters were compared between groups: presence of ovarian endometrioma, presence and number of deep infiltrating endometriosis (DIE) lesions and American Society for Reproductive Medicine score. The statistical analysis was performed with Statistica version 8.0, using the Fisher exact test, Student's t-test and Mann-Whitney test, when needed. A p value of <0.05 was considered to be statistically significant. RESULTS: During the study period, a total of 350 women were submitted to laparoscopic treatment of endometriosis. One hundred thirty patients (37.1%) had Ca-125>35 U/mL and 220 (62.9%) had Ca-12<35 U/mL. The presence of ovarian endometriomas (47.7 versus 15.9%), DIE lesions (99.6 versus 78.6%) and intestinal DIE lesions (60 versus 30.9%) was more frequent, and the AFSr score was higher (34 versus 6) in the former group. In the second analysis, excluding the patients with ovarian endometriomas (>35 U/mL=68 patients and <35 U/mL=185 patients), similar results were obtained. The presence of DIE lesions (91.2 versus 76.2%), intestinal DIE lesions (63.2 versus 25.4%), bladder DIE lesions (20.6 versus 4.8%) and ureteral DIE lesions (7.3 versus 1.6%) was more frequent, and the AFSr score was higher (10 versus 6) in the Ca-125 >35 U/mL group. CONCLUSIONS: Investigation for DIE is mandatory in women with pelvic pain symptoms suggestive of endometriosis with a preoperative Ca-125 level >35 U/mL, especially when an ovarian endometrioma is not present.

Assuntos

RESUMO

The surgical treatment of intestinal deep infiltrating endometriosis has an associated risk of major complications such as dehiscence of the intestinal anastomosis, pelvic abscess, and rectovaginal fistula. The management of postoperative rectovaginal fistula frequently requires a reoperation and the construction of a stoma for temporary fecal diversion. In this paper we describe a 27-year-old woman undergoing laparoscopic treatment of deep infiltrating endometriosis (extramucosal cystectomy, resection of the uterosacral ligaments, resection of the posterior vaginal fornix, and segmental bowel resection) complicated by a rectovaginal fistula, which healed spontaneously with nonsurgical conservative treatment.