ABSTRACT Introduction: Mucinous neoplasms of the cecal appendix are infrequent. These lesions can be an incidental finding in emergency appendectomies, since their preoperative diagnosis is difficult due to the lack of specificity of their symptoms. Objective: To present a case of low-grade mucinous neoplasia of the cecal appendix. Case Report: A 73-year-old male patient presented with acute abdominal pain, vital signs and laboratory tests within normal limits, and ultrasonography showing a cecal appendix measuring 76 ( 67 ( 107 mm. Radical appendectomy was performed, which included resection of the mesoappendix from the appendicular artery, the antimesenteric border of the ligament of Tréves and the free appendicular base, which included the cecum (cecectomy). In the histopathological examination it was observed that the cecal appendix belonged to 10 ( 8 ( 5 cm with tumor lesion in the base and part of the body; the cut showed outflow of viscous, mucoid, yellowish material, cystic areas of less than 1 cm, congestive vessels, presence of mucous glands with cells showing scarce atypia and an expansive invasion affecting the muscular and mucosal layer with focal loss and slight fibrosis of the submucosa. Low grade cecal appendiceal mucinous neoplasia of the appendix was diagnosed, with resolution and satisfactory evolution of the patient. Conclusions: Mucinous neoplasms of the cecal appendix may be an incidental finding. They have non-specific symptoms, are largely treated by resection and histopathological study is necessary for their diagnosis.

RESUMEN Introducción: Las neoplasias mucinosas del apéndice cecal son infrecuentes. Estas lesiones pueden ser un hallazgo incidental en las apendicetomías realizadas por urgencias, ya que su diagnóstico preoperatorio es difícil por la inespecificidad de sus síntomas. Objetivo: Presentar un caso de neoplasia mucinosa de apéndice cecal de bajo grado. Caso Clínico: Paciente masculino de 73 años de edad, que presenta dolor abdominal agudo, signos vitales y exámenes de laboratorio dentro de los límites normales, ecografía que informa apéndice cecal de 76 ( 67 ( 107 mm. Se realizó apendicetomía radical, que incluyó resección del mesoapéndice desde la arteria apendicular, el borde antimesentérico del ligamento de Tréves y la base apendicular libre, que incluyó el ciego (cequectomía). En el examen histopatológico se observó que al apéndice cecal pertenecen 10 ( 8 ( 5 cm con lesión tumoral en la base y parte del cuerpo; al corte se observó salida de material viscoso, mucoide, amarillento, áreas quísticas de menos de 1 cm, vasos congestivos, presencia de glándulas mucosas con células que muestran escasa atipia y una invasión expansiva que afecta la capa muscularis mucosae con pérdida focal y fibrosis ligera de la submucosa. Se diagnosticó neoplasia mucinosa de apéndice cecal de bajo grado, con resolución y evolución satisfactoria del paciente. Conclusiones: Las neoplasias mucinosas del apéndice cecal pueden resultar un hallazgo incidental. Tienen sintomatología inespecífica, se tratan en gran parte por resección y es necesario el estudio histopatológico para su diagnóstico.

ABSTRACT Hydatidosis or echinococcosis is an endemic parasitic disease caused by the ingestion of eggs of echinococcal species worldwide. In India, the annual incidence varies from 1 to 200 per one 100,000 hab., with the highest prevalence reported in the Indian states of Andhra Pradesh and Tamil Nadu. The dog is the definitive host, while humans, sheep, and cattle are intermediate hosts. The disease usually involves the liver and lungs, with the kidney and other organs rare involvement. Cardiac hydatidosis is still further rare, seen in 0.2% to 2% of the patients who remain asymptomatic until the development of its complications. Sudden deaths in cardiac echinococcosis are mostly attributed to cardiac arrhythmias, coronary artery diseases, valvular diseases, cardiomyopathies, pericarditis, and cardiac tamponade. We, herein, report a rare case of cardiac hydatid cyst incidentally found during the autopsy of a 26-year-old male who died due to electrical injuries. A single greyish-white cystic mass measuring 1.5cm X 1.2cm was detected on the left anterior ventricular wall 4 cm above the apex and was confirmed microscopically as a hydatid cyst. The cause of death was attributed to external injury. worldwide India 20 100000 100 000 100,00 hab hab. Nadu host humans sheep hosts lungs involvement 02 0 2 0.2 complications arrhythmias diseases cardiomyopathies pericarditis tamponade We herein 26yearold yearold 26 year old injuries greyishwhite greyish white 15cm 5cm 12cm 2cm injury 10000 10 00 100,0 0. 1000 100,

Cannabis legalisation continues to grow globally and its effects on the vascular system have been scrutinized.¹ Cannabis has become recognised as a contributor to cardiovascular, cerebrovascular and peripheral vascular disease.2,3 This case report highlights the case of a young male patient presenting with atypical symptoms following cannabis use who developed gangrenous cholecystitis (GC) following vasospasm of his cystic artery. We believe that this is the first-ever case, shared with the anticipation of stimulating more research and prompting recognition of vascular events in this group of patients as our knowledge on the effects of cannabis continues to grow.

Resumen El pseudoaneurisma de la arteria cística es una complicación poco frecuente de la colecistitis aguda. Su presentación se ha relacionado con daño inflamatorio de la adventicia o bien con origen traumático posterior a procedimientos invasivos. La angiografía es una modalidad tanto diagnóstica como terapéutica que permite su manejo mediante radiología intervencionista. Se presenta el caso de un varón de 60 años con un cuadro de colecistitis aguda y posterior deterioro de su condición clínica, asociado a hemobilia y compromiso hemodinámico, en quien se establece el diagnóstico de pseudoaneurisma roto de la arteria cística que es manejado de manera urgente mediante embolización transarterial y posterior colecistectomía laparoscópica.

Abstract Cystic artery pseudoaneurysm is an uncommon complication of acute cholecystitis. Its presentation has been related to the damage consequence of inflammation to the adventitia or traumatic due invasive procedures. Angiography is a diagnostic and therapeutic modality that allows its management through interventional radiology. We present the case of a 60-year-old man with acute cholecystitis and subsequent deterioration of his clinical condition, associated with hemobilia and hemodynamic compromise, in whom the diagnosis of ruptured cystic artery pseudoaneurysm was established and managed urgently by transarterial embolization and subsequent laparoscopic cholecystectomy.

ABSTRACT Aim: Renal leiomyoma is a rare benign mesenchymal tumor arising from the smooth muscle cells of the kidney. Renal capsule is its most common location (1). Large tumor may require surgical excision which can be challenging in case of proximity to major vessels (2). Indications of robotic partial nephrectomy (RPN) have exponentially expanded over the past few years (3). We aim to report a case of large renal leiomyoma successfully managed with RPN. Methods: A 59-year-old female patient with BMI 51 presented with chief complaint of abdominal discomfort. The patient underwent a CT scan that revealed a massive circumscribed exophytic complex solid cystic mass of 4.5 × 7.7 × 6.2 cm, arising from the lower pole of right kidney and abutting the inferior vena cava. RENAL score was 11ah (high complexity). Past surgical history included mid-urethral sling, breast reduction, and hysterectomy with salpingectomy. Preoperative creatinine and eGFR were 0.9 (mg/dL) and 77 (mL/min), respectively. A robotic excision of this mass was successfully performed by using Da Vinci Xi platform. Main steps of the procedure are illustrated in the present video. Results: Dissection and isolation of the tumor were carefully performed after identifying key anatomical structures such as the ureter, the IVC and the renal hilum. Intraoperative ultrasound was used to confirm the margins of the mass. The renal artery was clamped and then the tumor was resected/enucleated. Renal parenchyma was re-approximated with a single layer of interrupted CT-1 Vicryl 0 with sliding clip technique. Warm ischemia time was 19 min. Estimated blood loss (EBL) was 250 ml. Operative time was 165 min. No intraoperative complications occurred. No drain was placed. Patient was discharged on postoperative day 2. Post-operative hypotension was managed with fluid bolus. Postoperative creatinine and eGFR were 1,0 (mg/dL) and 69 (mL/min/1.72m2), respectively. Pathology revealed a leiomyoma of genital stromal origin with hyalinization and calcification. Conclusions: To the best of our knowledge, this is the first description of RPN for the management of a large (about 8 cm) renal leiomyoma. Robotic assisted surgery allows to expand the indications of minimally invasive conservative renal surgery whose feasibility becomes even more clinically significant in case of benign masses which can be managed without sacrificing healthy renal parenchyma. Aim 1. 1 . (1) 2 (2) (RPN 3. 3 (3) Methods 59yearold yearold 59 year old 5 discomfort 45 4 4. 7 7. 62 6 6. cm cava ah high complexity. complexity complexity) midurethral mid urethral sling reduction salpingectomy 09 9 0. mg/dL mgdL mg dL (mg/dL mL/min, mLmin mL/min , mL min (mL/min) respectively platform video Results ureter hilum resectedenucleated resected enucleated resected/enucleated reapproximated re approximated CT1 CT- technique EBL (EBL 25 ml 16 occurred placed Post operative bolus 10 1, mL/min/1.72m2, mLmin172m2 mLminm mL/min/1.72m2 72m2 m (mL/min/1.72m2) calcification Conclusions knowledge about (1 (2 (3 (mL/min mLmin172m mL/min/1.72m 72m (mL/min/1.72m2 ( (mL/min/1.72m

SUMMARY We present the case of a 55-year-old male patient with a history of acute cholecystitis who presented during his hospitalization haemobilia due to a pseudoaneurysm of the cystic artery. Embolectomy of the cystic artery with polyvinyl alcohol microparticles was performed stopping the bleeding.

RESUMEN Se presenta el caso de un paciente varón de 55 años con antecedente de colecistitis aguda, que durante la hospitalización presentó anemia por hemobilia secundaria a un pseudoaneurima de la arteria cistica. Se realizó, como tratamiento de primera elección, embolización con microparticulas de alcohol polivinílico (PVA) de la arteria cistica, logrando detención del sangrado.

RESUMO Objetivo: A hemoptise maciça é uma das complicações mais graves em pacientes com fibrose cística (FC). O objetivo deste estudo foi avaliar o período livre de hemoptise após a embolização arterial brônquica/não brônquica (EAB/não EAB) em pacientes com FC e investigar preditores de sangramento recorrente e mortalidade por qualquer causa. Métodos: Trata-se de um estudo retrospectivo de coorte de pacientes com FC com idade ≥ 16 anos submetidos a EAB/não EAB para o tratamento de hemoptise entre 2000 e 2017. Resultados: Foram analisados 39 episódios de hemoptise tratada por meio de EAB/não EAB em 17 pacientes com FC. A taxa de recidiva da hemoptise foi de 56,4%. Do total de pacientes, 3 (17,6%) permaneceram sem hemoptise durante o estudo, 2 (11,8%) foram submetidos a transplante de pulmão e 3 (17,6%) morreram. A mediana do período sem hemoptise foi de 17 meses. A mediana do período sem hemoptise foi maior em pacientes com infecção crônica por Pseudomonas aeruginosa (31 meses; IC95%: 0,00-68,5) do que naqueles sem esse tipo de infecção (4 meses; IC95%: 1,8-6,2; p = 0,017). No entanto, essa associação foi considerada fraca, e sua importância clínica foi considerada incerta em virtude do pequeno número de pacientes sem essa infecção. Conclusões: A EAB parece ser eficaz no tratamento de hemoptise em pacientes com FC.

ABSTRACT Objective: Massive hemoptysis is one of the most serious complications in patients with cystic fibrosis (CF). This study aimed to evaluate the hemoptysis-free period following bronchial and non-bronchial artery embolization (BAE/non-BAE) in CF patients and to investigate predictors of recurrent bleeding and mortality by any cause. Methods: This was a retrospective cohort study of CF patients ≥ 16 years of age undergoing BAE/non-BAE for hemoptysis between 2000 and 2017. Results: We analyzed 39 hemoptysis episodes treated with BAE/non-BAE in 17 CF patients. Hemoptysis recurrence rate was 56.4%. Of the sample as a whole, 3 (17.6%) were hemoptysis-free during the study period, 2 (11.8%) underwent lung transplantation, and 3 (17.6%) died. The median hemoptysis-free period was 17 months. The median hemoptysis-free period was longer in patients with chronic infection with Pseudomonas aeruginosa (31 months; 95% CI: 0.00-68.5) than in those without that type of infection (4 months; 95% CI: 1.8-6.2; p = 0.017). However, this association was considered weak, and its clinical significance was uncertain due to the small number of patients without that infection. Conclusions: BAE appears to be effective in the treatment of hemoptysis in patients with CF.

Visceral larva migrans (VLM) occurs because of a host inflammatory response to the migrating larvae of a nematode. Patients usually present with fever, hepatomegaly and abdominal pain; vascular arterial complications are uncommon. A 19-year female presented with fever, jaundice, abdominal discomfort and melena. Computed tomography (CT) revealed multiple discrete, clustered, complex hepatic cystic lesions consistent with VLM, along with an arterial pseudoaneurysm from the right hepatic artery which was managed with endovascular coil embolisation.

Resumo A doença quística da adventícia é uma condição rara. Afecta sobretudo a artéria poplítea, com poucos casos relatados que afectem a artéria radial. Esta doença é caracterizada pela acumulação de um conteúdo mucinoso na camada adventícia.

Abstract Adventitial cystic disease (ACD) is a rare condition. It affects mostly the popliteal artery, with few cases reported affecting the radial artery. This condition is characterized by accumulation of mucinous content at the adventitious layer.

Abstract Cystic adventitial disease of the popliteal artery is a rare disease that usually mani-fests with intermittent claudicating. Patients are usually young and without risk fac-tors for atherosclerosis. In this report, we present a case of a 52 years old man with thrombosis of popliteal artery which recanalized spontaneously a year later. Given the persistence of claudi-cating and the suspicion of cystic adventitial disease, we decided to perform resection of the affected artery and revascularization with prosthetic grafting.

Resumen La enfermedad quística adventicial (EQA) de la arteria poplítea es una enfermedad poco frecuente. El síntoma más frecuente es la claudicación. Los pacientes suelen ser jóvenes y sin factores de riesgo para ateroesclerosis. Presentamos el caso de un paciente de 52 años con clínica de claudicación y hallazgo de trombosis de la arteria poplítea que al año recanalizó espontáneamente. Dada la persistencia de la clínica y la lesión sospechosa de quiste poplíteo, se decidió realizar la resección de dicha lesión y la revascularización mediante injerto protésico.

SUMMARY: Laparoscopic cholecystectomy is the treatment of cholelithiasis of choice; however, it is accompanied by comorbidities and is not exempt from major complications that can be lethal; the identification of the cystohepatic trigone with dissection and ligation of the cystic artery are mandatory steps of surgery; the identification of the variations of the cystic artery and the bile ducts can minimize the possible complications. The preoperative protocol was implemented with an angiotomography with Siemens Somatón Sensation ® 64-slice Tomograph to identify the cystic artery in patients with cholelithiasis of the General Surgery Unit of the Teodoro Maldonado Carbo IESS Specialty Hospital of Guayaquil. 60 female patients were chosen at random (ages 19 -70 years, average 44.25 years) and the sample was divided into two groups of 30; Angiotomography was applied to the study group up to one month before surgery and the conventional protocol was applied to the control group. Morbidities related to: operative haemorrhage due to cystic artery and postoperative injury: operative wound infection, ileus and drainage were evaluated. Angiotomography allowed to identify the cystic artery in the preoperative period and contributed to decrease comorbidities that accompany laparoscopic cholecystectomy.

RESUMEN: La colecistectomía laparoscópica es el tratamiento de elección de la colelitiasis; sin embargo, se acompaña de comorbilidades y no está exenta de complicaciones mayores que pueden ser letales; la identificación del trígono cistohepático con disección y ligadura de la arteria cística son pasos obligatorios de la cirugía; la identificación de las variaciones de la arteria cística y los conductos biliares pueden minimizar las eventuales complicaciones. Al protocolo preoperatorio se implementó una angiotomografía con Tomógrafo Siemens Somatón Sensation ® de 64 cortes para identificar la arteria cística en pacientes con colelitiasis de la Unidad de Cirugía General del Hospital de Especialidades Teodoro Maldonado Carbo IESS de Guayaquil. Se escogieron 60 pacientes femeninos en forma aleatoria (edades 19-70 años, promedio 44,25 años) y la muestra se dividió en dos grupos de 30; al grupo estudio se aplicó angiotomografía hasta un mes antes de la cirugía y al grupo control se le aplicó el protocolo convencional. Se evaluó morbilidades relacionadas con: hemorragia operatoria por lesión de la arteria cística y en el posoperatorio: infección de herida operatoria, íleo y drenaje. La angiotomografía permitió identificar la arteria cística en el preoperatorio y contribuyó a disminuir comorbilidades que acompañan a la colecistectomía laparoscópica.

O pseudoaneurisma da artéria cística é uma entidade rara, que pode resultar de patologia inflamatória (colecistite aguda ou pancreatite) ou trauma iatrogénico (colecistectomia). Apresentamos o caso de uma mulher de 73 anos que se apresentou com dor abdominal e hemorragia digestiva após um episódio de colecistite aguda e CPRE para remoção de coledocolitíase. A TC e a angiografia revelaram um pseudoaneurisma da artéria cística com 5 cm. Foi realizada embolização da artéria hepática direita com cola, com exclusão do pseudoaneurisma. No dia seguinte a paciente foi submetida a colecistectomia com ligação da artéria cística. Posteriormente, desenvolveu-se hepatite isquémica e abcesso hepático.

Cystic artery pseudoaneurysm (CAP) is a rare entity most often resulting from inflammatory conditions (acute cholecystitis or pancreatitis) or iatrogenic trauma (cholecystectomy). We report the case of a 73-year-old female who presented with abdominal pain and gastrointestinal bleeding after an episode of acute cholecystitis and endoscopic retrograde cholangiopancreatography for choledocolithiasis removal. Computed tomography and angiography revealed a CAP measuring 5 cm. A right hepatic artery transcatheter embolization was performed with glue, excluding the pseudoaneurysm. The next day, the patient underwent open cholecystectomy with ligation of the cystic artery. Later, ischemic hepatitis and abscess developed.

SUMMARY: This is an anatomical study with the special and small dissection of a laparoscopic cholecystectomy on the surgically important variations of the cystic artery. A prospective, 19-month study was conducted in 2000, including consecutive patients undergoing programmed laparoscopic cholecystectomy, without signs of acute inflammation, or alteration, that would prevent dissection and correct evaluation of the cystohepatic triangle. It was surgically dissected, identifying the main cystic artery and its possible collateral arteries. Those with a diameter greater than 1.5 mm being considered as clinically important, requiring haemostatic maneuver (clipping and / or electrocoagulation). The findings were recorded on a special form for the purposes of this study. The classic, single-artery arrangement in the middle of the cystohepatic triangle was found in 1831 cases. The variations found were 169 (8.45 %). In 97 cases there was double vascularization, with one artery in normal position and another outside the cystic duct. In 44 patients, a single artery that did not cross the cystic was observed. In 22 cases an artery outside the cystic but crossing it before the duct. In 6 cases a double artery, one in the cystohepatic triangle and another outside the triangle, did not cross the cystic or the bile duct. In one instance, a single major artery was seen emerging directly from the cystic plaque between segments four and five. These can be divided into single or double arteries, based exclusively on the need for hemostatic maneuver. Knowledge of anatomical variations of the cystic artery is important for the surgeon. The variation presents in 1 of 12 cases, and requires a special hemostatic maneuver in 1 of 20 cases.

RESUMEN: Realizar un estudio anatómico in vivo con la especial y pequeña disección quirúrgica durante una colecistectomía laparoscópica sobre las variaciones de la arteria cística. Estudio prospectivo de 38 meses, en 2000 pacientes consecutivos sometidos a colecistectomía laparoscópica programada, sin signos de inflamación aguda, ni alteración que impida disección y correcta evaluación del triángulo hepatocístico. Se disecó quirúrgicamente identificándose la arteria cística y posible duplicación, eran clínicamente importantes aquellas con diámetro mayor a 1,5 mm, requerían maniobra hemostática. Se anotaron los hallazgos en planilla especial a los fines del presente estudio. En 1831 casos había arteria única en medio del triángulo hepatocístico. Hubo 169 variaciones (8,45 %). En 97 casos: doble vascularización, con una arteria en situación normal y otra ubicada lateralmente al triangulo hepatocístico. En 44 pacientes había una arteria única lateralmente al conducto cístico que no lo cruzaba nunca. En 22 casos existía una arteria cruzando el colédoco y el cístico entrando en el triángulo. En 6 oportunidades una doble arteria, una en el triángulo hepatocístico y otra lateralmente que no cruzaba el cístico ni colédoco. En una oportunidad se observó una sola arteria importante que salía directamente de la placa cística entre segmento 4 y 5, y en otro caso solo pequeñas arterias proveniente de la placa cística. Podemos dividirlas en arterias únicas o dobles, en base exclusiva a la necesidad de maniobra hemostática. Podemos decir que las variaciones estarán presentes en aproximadamente 1/12 casos y necesitará una maniobra hemostática especial en 1/20 casos.