Management of Nontraumatic Spontaneous Renal Hemorrhage (Wünderlich Syndrome) through Robotic-Assisted Laparoscopic Nephrectomy: A Case Series

BACKGROUND Wünderlich syndrome (WS) is a rare diagnosis of nontraumatic spontaneous renal hemorrhage into the subcapsular, perirenal, or pararenal spaces. Prompt and effective intervention is necessary for an accurate pathological diagnosis and preservation of life. In the current literature, open surgery is the primary option when conservative treatment fails, but there can be serious trauma and corresponding consequences. Herein, we present 3 cases of Wünderlich syndrome managed by robot-assisted laparoscopic nephrectomy via a retroperitoneal approach. CASE REPORT Patient 1 was a 44-year-old woman with right flank pain for 6 h. Patient 2 was a 53-year-old woman with a history of diabetes who had pain in her right flank pain and nausea for 1 day. Patient 3 was a 45-year-old man with left flank pain for 1 day. All cases of WS were confirmed by CT. All 3 patients were treated with retroperitoneal robot-assisted nephrectomy after conservative treatment failed. Pathological examination confirmed that patient 1 had angiomyolipoma, and patients 2 and 3 had renal clear cell carcinoma. At the 9-month follow-up, renal function was good and no evidence of recurrence or metastasis has been detected. CONCLUSIONS These cases have highlighted the importance of the clinical history and imaging findings in the diagnosis of Wünderlich syndrome, and show that rapid management can be achieved using robot-assisted laparoscopic nephrectomy. However, it is crucial to have a skilled surgical team and adequate preoperative preparation.

Prevalence and factors associated with the perception of perineal laceration: a cross-sectional study with data from the Nascer no Brasil Survey, 2011 and 2012

OBJECTIVE

To describe the prevalence of perineal laceration, based on the self-reported perception of postpartum women, and to analyze factors associated with its occurrence in Brazil.

METHODS

This was a cross-sectional study conducted with 23,894 postpartum women, excluding twin pregnancies, cesarean sections, and births with episiotomies, between 2011 and 2012. Prevalence ratios (PR) and 95% confidence intervals (95%CI) of association between the event and maternal, fetus/newborn, obstetric and clinical management characteristics were estimated in hierarchical Poisson regression models.

RESULTS

Out of 4,606 postpartum women, 49.5% (95%CI 46.1;42.9) self-reported perineal laceration. Being an adolescent (PR = 1.12; 95%CI 1.02;1.25), primipara (PR = 1.47; 95%CI 1.33;1.63), having had excessive gestational weight gain (PR = 1.17; 95%CI 1.07;1.29) and having undergone the Kristeller maneuver (PR = 1.18; 95%CI 1.08;1.29) increased the proportion of the outcome.

CONCLUSION

The results found call for prenatal care and adjustments to childbirth care so as to be in accordance with current recommendations.

MAIN RESULTS

Prevalence of self-reported perineal laceration was 49.5%. Being in the adolescent age group, primiparity, excessive gestational weight and the Kristeller maneuver were risk factors associated with the event.

IMPLICATIONS FOR SERVICES

Studying self-reported prevalence of perineal laceration supports new care practices, highlights the prevention of risk factors considered modifiable and confirms the need to follow current guidelines.

PERSPECTIVES

New national studies are needed comparing prevalence of self-reported perineal laceration with that recorded in medical records in order to support care practices and public obstetric policies.

Liver rupture in a 28-year-old primigravida with superimposed pre-eclampsia and hemolysis, elevated liver enzyme levels, and low platelet count syndrome

Serious hepatic complications, although rare, are one of the leading causes of maternofetal morbidity and mortality in hypertensive pregnancy disorders. A 28-year-old primigravida was transferred to our hospital complaining of refractory epigastric pain in the 29th week of pregnancy and was subsequently admitted due to superimposed pre-eclampsia and hemolysis, elevated liver enzyme levels, and low platelet count syndrome. Following a pathological cardiotocogram, a cesarean section was performed. The intra-abdominal situs presented with 1000 mL of blood and a bleeding rupture of the left lobe of the liver. The trauma to the liver was surgically repaired with a suture and the patient's state was stabilized. Following the surgical procedures and neonatal intensive care, mother and newborn both recovered without residues. In order to avoid unnecessary maternal morbidity, we therefore recommend an abdominal ultrasound, beyond an obstetric focus, as an additional and sensible means of diagnostic imaging in cases of hemolysis, elevated liver enzyme levels, and low platelet count syndrome.

Bioresorbable Scaffolds in Spontaneous Coronary Artery Dissection: Long-Term Follow-Up in 4 Patients

Spontaneous coronary artery dissection is a rare condition, and diagnosis and treatment are challenging among patients who present with acute coronary syndrome. Typically, the condition affects young females who have no underlying atherosclerotic disease. To date, few cases of bioresorbable scaffold implantation for the treatment of spontaneous coronary artery dissection have been reported. Therefore, we describe the cases of 4 patients whom we treated with scaffolds. We evaluated the long-term results by using intravascular ultrasound and optical coherence tomographic scanning.

Left Circumflex Coronary Artery as the Culprit Vessel in ST-Segment-Elevation Myocardial Infarction

The prevalence of the left circumflex coronary artery (LCx) as the culprit vessel in ST-segment-elevation myocardial infarction (STEMI) is reportedly lowest among that of the 3 main epicardial arteries, and has not been described for non-STEMI (NSTEMI) and stable angina pectoris. We sought to define the distribution of culprit arteries in these clinical presentations and suggest mechanisms for the differences. We reviewed 189 coronary angiograms of patients with STEMI, 203 with NSTEMI, and 548 with stable angina (n=940), and compared distributions of stenotic and culprit coronary arteries (lesions prompting intervention). Obstructive coronary lesions (≥50% narrowing) were more prevalent in the left anterior descending coronary artery (LAD) (36%-38%) and similar in the LCx and right coronary artery (RCA) (27%-29%), regardless of clinical presentation (P <0.01). In NSTEMI and stable angina, culprit vessels and total obstructive disease had the same distribution. In STEMI, however, a culprit LCx was significantly less prevalent (17%) than was total obstructive disease (27%; P <0.01), or a culprit LAD (47%) or RCA (34%) (both P <0.001). In our computed tomographic angiographic model of coronary longitudinal strain (percentage of shortening), LCx strain was only 1.5% ± 2.4%, versus 9.5% ± 2.9% for LAD strain and 10.1% ± 3.9% for RCA strain. In STEMI, LCx plaques seem less prone to rupturing. Culprit and total disease distributions are similar in NSTEMI and angina, suggesting a different ischemic pathophysiology in these presentations. Lower LCx longitudinal strain might contribute to reduced plaque rupture in STEMI.

Inflammation and Rupture of a Congenital Pericardial Cyst Manifesting Itself as an Acute Chest Pain Syndrome

We present the case of a 63-year-old woman with a remote history of supraventricular tachycardia and hyperlipidemia, who presented with recurrent episodes of acute-onset chest pain. An electrocardiogram showed no evidence of acute coronary syndrome. A chest radiograph revealed a prominent right-sided heart border. A suspected congenital pericardial cyst was identified on a computed tomographic chest scan, and stranding was noted around the cyst. The patient was treated with nonsteroidal anti-inflammatory drugs, and the pain initially abated. Another flare-up was treated similarly. Cardiac magnetic resonance imaging was then performed after symptoms had resolved, and no evidence of the cyst was seen. The suspected cause of the patient's chest pain was acute inflammation of a congenital pericardial cyst with subsequent rupture and resolution of symptoms.

Boerhaave syndrome - case report

CONTEXT:

Boerhaave syndrome consists of spontaneous longitudinal transmural rupture of the esophagus, usually in its distal part. It generally develops during or after persistent vomiting as a consequence of a sudden increase in intraluminal pressure in the esophagus. It is extremely rare in clinical practice. In 50% of the cases, it is manifested by Mackler's triad: vomiting, lower thoracic pain and subcutaneous emphysema. Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Compared with ruptures of other parts of the digestive tract, spontaneous rupture is characterized by a higher mortality rate.

CASE REPORT:

This paper presents a 64-year-old female patient whose vomit was black four days before examination and became bloody on the day of the examination. Her symptoms included epigastric pain and suffocation. Physical examination showed hypotension, tachycardia, dyspnea and a swollen and painful abdomen. Auscultation showed lateral crackling sounds on inspiration. Ultrasound examination showed a distended stomach filled with fluid. Over 1000 ml of fresh blood was extracted by means of nasogastric suction. Esophagogastroduodenoscopy was discontinued immediately upon entering the proximal esophagus, where a large amount of fresh blood was observed. The patient was sent for emergency abdominal surgery, during which she died. An autopsy established a diagnosis of Boerhaave syndrome and ulceration in the duodenal bulb.

CONCLUSION:

Boerhaave syndrome should be considered in all cases with a combination of gastrointestinal symptoms (especially epigastric pain and vomiting) and pulmonary signs and symptoms (especially suffocation).

Spontaneous Coronary Artery Dissection with Cardiac Tamponade

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. Clinical presentation ranges from chest pain alone to ST-segment-elevation myocardial infarction, ventricular fibrillation, and sudden death. The treatment of patients with spontaneous coronary artery dissection is challenging because the disease pathophysiology is unclear, optimal treatment is unknown, and short- and long-term prognostic data are minimal. We report the case of a 70-year-old woman who presented with an acute ST-segment-elevation myocardial infarction secondary to a spontaneous dissection of the left anterior descending coronary artery. She was treated conservatively. Cardiac tamponade developed 16 hours after presentation. Repeat coronary angiography revealed extension of the dissection. Medical therapy was continued after the hemopericardium was aspirated. The patient remained asymptomatic 3 years after hospital discharge. To our knowledge, this is the first reported case of spontaneous coronary artery dissection in association with cardiac tamponade that was treated conservatively and had a successful outcome.

Postpartal dissection of all coronary arteries in an in vitro-fertilized postmenopausal woman

Myocardial infarction complicates approximately 1 in 10,000 pregnancies. Although coronary artery dissection is the leading cause of pregnancy-related myocardial infarction during the postpartum period, the pathogenesis of coronary dissection during this period remains uncertain.Herein, we report the case of a 52-year-old black postmenopausal woman with no apparent cardiovascular risk factors who gave birth to twins after in vitro fertilization. Ten days after delivery, she presented with an acute coronary syndrome. Coronary angiography revealed dissection of all 3 coronary arteries. Despite aggressive medical management, the patient experienced recurrent myocardial ischemia. Repeat coronary angiography revealed progression of the dissection process, which required urgent coronary artery bypass surgery. The patient's postoperative course was uneventful. To our knowledge, this report is the 1st description of pregnancy-associated coronary artery dissections in a postmenopausal woman, and the 1st such event in a pregnancy that resulted from in vitro fertilization.

Clostridium septicum aortitis causing aortic dissection in a 22-year-old man

Clostridium septicum infection is a rare cause of aortic dissection, and the mortality rate for the condition is high. Only 26 cases of C. septicum aortitis have been reported; all of those patients were elderly, and 20 of them had an associated colonic neoplasm. Herein, we present the case of a 22-year-old man whose C. septicum aortitis resulted in aortic dissection that involved the entire length of the aorta. Upon autopsy, no neoplasm or other predisposing condition was identified in this patient. To the best of our knowledge, this is the 1st report of C. septicum aortitis, fatal or otherwise, in a young individual.

Massive spontaneous hemothorax during the immediate postpartum period

Nontraumatic hemothorax is a rare cause of postpartum respiratory distress. We present a case of massive spontaneous hemothorax, which presented during the immediate postpartum period and was initially treated as pulmonary embolism. Further investigation revealed a tiny lung nodule: although pulmonary arteriovenous malformation was considered, the imaging appearances tended to counter this interpretation. Eventually, in the absence of another cause for spontaneous hemothorax, on either clinical or imaging grounds, we diagnosed spontaneous arteriovenous malformation. Its management is discussed herein.

Usefulness of laboratory data in the management of right iliac fossa pain in adults

PURPOSE

This study examined the usefulness of inflammatory markers in the management of patients with right iliac fossa pain.

PATIENTS AND METHODS

A single site, prospective observational study was conducted from October 2001 to April 2003. Patients with right iliac fossa pain referred to the surgeon were included. Blood samples were obtained for C-reactive protein, leukocyte, and granulocyte analysis. Clinical, surgical, and histopathologic data were collected. Analysis of inflammatory parameters was performed with logistic regression and areas under the receiver operating characteristic curve were compared.

RESULTS

C-reactive protein increased with the severity of appendicitis and predicted accurately perforation (r(2) = 0.613; P < 0.0005), showing the highest accuracy among inflammatory markers (areas under the receiver operating characteristics curve were 0.846, 0.753, and 0.685 for C-reactive protein, leukocyte and granulocytes, respectively; P < 0.001). Accuracy improved when C-reactive protein and leukocytes were combined; positive and negative predictive values were 93.2 percent and 92.3 percent, respectively.

CONCLUSIONS

C-reactive protein is a helpful marker in the management of patients with right iliac fossa pain; the predictive value improves when combined with leukocyte count. A patient with normal C-reactive protein and leukocytes has a very low probability of appendicitis and should not undergo surgery.

Surgical management of spontaneous coronary artery dissection

Spontaneous coronary artery dissection, which causes acute coronary syndrome and can result in sudden death, is rare; but its true incidence is underestimated, since most patients die suddenly, without diagnosis. The aim of this study was to show the importance of prompt diagnosis and treatment. In reviewing the records of 5,000 consecutive patients who underwent coronary angiography between January 2001 and August 2006, we found 6 cases of spontaneous coronary artery dissection (an incidence rate of 0.12%). Five patients presented with left main coronary artery dissection and 1 patient, with right coronary artery dissection. Angioplasty with stenting failed in the patient with right coronary artery dissection. Coronary artery bypass surgery was performed in all patients. The patient with right coronary artery dissection died of sepsis on the 30th postoperative day. The other 5 patients (83.3%) are still free of symptoms, and they had negative results on stress tests at the 6- and 12-month follow-up visits after coronary artery bypass surgery. The clinical presentation of spontaneous left main coronary artery dissection was similar to that of atherosclerotic disease. However, early diagnosis of spontaneous coronary artery dissection by means of coronary angiography is of paramount importance, because urgent coronary artery bypass grafting can be lifesaving.

Spontaneous rupture of the superficial femoral artery treated via an endovascular approach

Isolated spontaneous rupture of the superficial femoral artery is very uncommon. To our knowledge, only 5 other cases have been reported in the medical literature. Herein, we report the case of an 86-year-old woman who was admitted to our hospital with a 4-day history of progressive swelling of the left thigh. The presence of a pulsating mass with paresthesia of the lower limb and anemia suggested a hematoma of the thigh. A computed tomographic scan revealed a 4-cm-diameter pseudoaneurysm of the left superficial femoral artery and a large hematoma of the medial muscle compartment. A nitinol-polytetrafluoroethylene VIABAHN self-expanding stent-graft (5-mm diameterx50-mm length) was placed beyond the arterial lesion, and a fasciotomy of the thigh was performed. On the 10th postoperative day, the patient was discharged from the hospital in good condition. In cases of spontaneous swelling of the thigh in the absence of trauma or other apparent causes, spontaneous rupture of the superficial femoral artery should be suspected. Surgical treatment is preferable in young patients. In patients who are elderly or in poor condition, endovascular therapy is preferable when there is diffuse atherosclerosis of the artery.

Free intra-abdominal hemorrhage after open-heart surgery: an unusual gastrointestinal complication

Gastrointestinal complications after open-heart surgery are rare. Many preoperative, intraoperative, and postoperative factors may predispose patients to these complications or cause them. Our patient was a 64-year-old woman who underwent aortic valve replacement due to aortic stenosis. Free intra-abdominal hemorrhage occurred on the 2nd postoperative day. During exploratory laparotomy, it was determined that the hemorrhage was from a vein near the falciform ligament of the liver and from a bleeding laceration of the splenic capsule. The complication was repaired surgically. To our knowledge, intra-abdominal hemorrhage of both liver and spleen after open-heart surgery has never been reported before, even in large patient series. We report the case and present our ideas regarding the cause of the bleeding.

Survival of an octogenarian after rupture of the left ventricular free wall caused by myocardial infarction

Left ventricular free wall rupture is an uncommon complication after a myocardial infarction that is associated with a high mortality rate from pericardial tamponade, especially in the elderly. Early recognition and management of this clinical entity affects the outcome; therefore, a high index of suspicion is imperative. We present a case of an 80-year-old man admitted with myocardial infarction, who had subsequent findings of left ventricular free wall rupture complicated by pericardial tamponade. Emergent surgical repair led to successful recovery. A brief overview of the clinical presentation, diagnosis, and management of this challenging and potentially fatal complication is presented.

Aorta-left renal vein fistula in a woman

Spontaneous rupture of an abdominal aortic aneurysm into a retroaortic left renal vein is an uncommon occurrence. A 55-year-old woman presented with shortness of breath, vomiting, and diffuse abdominal pain that had radiated to her back and legs for the preceding 10 days. A pulsatile abdominal mass, hematuria, renal insufficiency, and heart failure were present at the initial evaluation. Computed tomography showed an infrarenal abdominal aortic aneurysm that communicated with a retroaortic left renal vein. After urgent surgical repair, cardiac and renal function were dramatically improved. To the best of our knowledge, this is the 1st reported case of a woman with such a fistula. We review treatments reported in the literature.