Unbounded Medicine

This is how a Crohn’s disease looks in colonoscopy.

This is a case of a 67 years old male with history of chronic constipation (20 years) and chronic hemorrhoidal disease came to the office with rectal bleeding and a non-redicible anal mass.

On physical examination we found Grade IV hemorrhoidal disease.

We decide to perform a PPH procedure with an hemorrhoidal circular stapler (33 mm) kit.

Note the tissue removed.

This donut confirms the circular and complete resection of the defect.

On the postoperatory period the patient was in excellent condition without pain and without bleeding.

A previously healthy 27 years old female came to the emergency department with a chief complaint of one-month diffuse and intermitent abdominal pain, transitory relief with bowel movements, nausea without vomit, early saciety, postprandial fullness and weight loss of 4 kilos in 1 month.

On the physical exam, we found a 10×15 cm tumor in the left upper quadrant. The tumor is not fixed, it feels solid and well delimited. We did not find any other important data.

Lab work beteween normal ranges. We ordered plain abdominal film, chest x ray and later an abdominal ultrasound and a CT scan.

Rx

Ultrasound

CT Scan

With these findings, we decided to perform an exploratory laparotomy (left subcostal incision) and tumor resection.

Look the size of the tumor and its characteristics.

Note the splenic vein.

The tumor arises from the tail of the pancreas. It was impossible to dissect the spleen, so we had to cut it.

Pathology

Final diagnosis: Benign Solid Pseudopapillary Tumor of the Pancreas of 14 cm, and 1.66Kg.

Solid-pseudopapillary tumor (SPT) of pancreas is a very rare (about 450 cases have been described in the world literature) neoplasm of low malignant potential and unknown origin. It generally occurs in young women and the prognosis is usually good after complete surgical removal.

SPT is also know as Fratz’s tumor

A 68 year old female patient came to the E.D. with a chief complaint of sudden, severe epigastric pain, retching without vomitus and distention of the upper abdomen.

The patient was alert, very anxious, and in severe pain.
blood pressure of 160/120; pulse of 126; respiratory rate of 24; normal temperature; SatO2 of 96% without O2 supplement.
She had a distended upper abdomen and epigastric tenderness without rebound or guarding.

A plain film of the abdomen was ordered and showed gas-filled, grossly dilated stomach.

Pass of nasogastric tube was unsuccessful.

A laparotomy was mandatory.

The patient survived the surgery but 6 months later, she died by causes nonrelated to the surgery

In 1904, Borchardt described the classic triad of gastric volvulus: severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube.

This is the case of a 69 years old diabetic female patient with history of subtotal colectomy for advanced colon cancer a year ago.

She had a surgical complication of the abdominal wall called postincisional hernia and came to surgical consult because of this giant ventral hernia. This is one of the largest hernias I’ve ever seen.

A laparoscopic repair of the defect was made with Prolene mesh (2 sheets of 12″ x 12″) sutured to the fascia and now she is doing very well.

Images courtesy of Mariana Herrera Guerrero, M.D.

Previous proof of firecrackers injuries here.

For those who don’t believe in injuries caused by firecrackers explotion. I just saw a patient in the E.R. of my hospital who came because he was walking near a park and some kids were buying firecrakers in the street. A kid ignited a firecracker and it exploted next to the box that containded the firecrackers. The patient was 10 ft away from the box and the explotion cause this right side injuries.

As you can see, the injuries are projectile-like injuries and he didn’t burn. A witness told me that lots of wood sticks and asphalt stones flew far away.

A Plastic Surgeon and I repaired the injuries and noted an irregular perforation at the right cheek, that penetrated towards the floor of the orbit and produced a coronoid apophysis fracture.

After the reparation:

I strongly recommend never play with firecrackers.

This is the previously patented surgical retractor developed by Dr. Ángel Raúl Soriano Sánchez (Mexican Ob/Gyn from the National Institute for Social Security – IMSS) in action.

Beware! Gory Image

This amazing invention looks useful, isn’t it?