Jorge Pereira

Introduction: Obesity is a prevalent disease with a continuously rising global incidence. Bariatric surgery, particularly Roux-en-Y gastric bypass (RYGB), is an effective long-term treatment for morbid obesity, but it may be associated with late complications, including marginal ulcers and gastrogastric fistulas. Although uncommon, these complications can present with a wide clinical spectrum and may require complex management strategies. Case report: We report the case of a 52-year-old woman with a history of RYGB 4 years earlier who presented to the emergency department in septic shock. Abdominal examination revealed generalized tenderness with guarding. An abdominal X-ray demonstrated pneumoperitoneum. The patient underwent an emergent exploratory laparotomy, which revealed a perforated marginal ulcer associated with a gastrogastric fistula. Damage-control surgery was undertaken with remnant gastrectomy, Roux-limb resection, and temporary abdominal closure. A staged surgical approach was used, with delayed reconstruction via esophagojejunal anastomosis and placement of a feeding jejunostomy. Despite a complicated postoperative course, the patient recovered and was discharged in good clinical condition. Histological examination showed no malignancy. Discussion: Surgical intervention remains the definitive treatment in hemodynamically unstable patients with perforation and uncontrolled intra-abdominal sepsis following bariatric procedures. The authors present a rare case of an acute perforated marginal ulcer associated with a gastrogastric fistula in septic shock, successfully managed using a damage-control approach. Conclusion: Early recognition and prompt individualized management are crucial in severe post–RYGB complications. In critically ill patients, damage control surgery with a staged approach may represent a reasonable strategy to achieve source control and improve outcomes.

O traumatismo crânio-encefálico ligeiro representa globalmente cerca de 80% dos traumas de crânio. Apesar da sua aparente benignidade, existem custos e sequelas elevados. A avaliação das vítimas deve seguir uma lógica de estratificação de gravidade para a decisão da abordagem subsequente. O uso sistemático da tomografia é consensual como ferramenta de diagnóstico nos casos moderados ou graves, mas permanece controverso nos casos ligeiros. Nos últimos anos, os biomarcadores séricos emergem como uma ferramenta objetiva e complementar na estratificação do risco de lesão. A proteína ácida fibrilar glial e a ubiquitina C-terminal hidrolase L1 auxiliam a tomada de decisão em doentes com escala de coma de Glasgow entre 14 e 15 nas primeiras 12 horas após trauma. Neste consenso, pretende-se estabelecer um algoritmo de decisão baseado na conjugação de scores clínicos como o Canadian CT Head Rule (elevada sensibilidade) e biomarcadores. O algoritmo tem como principal objetivo homogeneizar a abordagem, baseando-se na evidência e procurando reduzir a exposição a radiações e a permanência no serviço de urgência, promovendo, em simultâneo, altas com segurança clínica. Nos casos de risco moderado, quando a proteína ácida fibrilar glial e a ubiquitina C-terminal hidrolase L1 são negativas nas primeiras 12 h após trauma, a necessidade de tomografia computorizada crânio-encefálica é excluída pelo elevado valor preditivo negativo destes biomarcadores, permitindo a alta salvo outra indicação clínica. Todos os doentes de alto risco farão tomografia computorizada crânio-encefálica, os sob terapêutica antitrombótica adicionalmente biomarcadores: ambos resultados negativos permitem considerar alta; ambos resultados positivos implicam admissão, se tomografia computorizada negativa e pelo menos um dos biomarcadores positivo sugere-se: repetição da tomografia computorizada crânio-encefálica em doentes com idade igual ou superior a 75 anos, em virtude de valores elevados séricos mesmo na ausência de trauma em 95% deste subgrupo e da inexistência à data de cut-offs ajustados à idade; devem repetir-se biomarcadores se idade inferior a 75 anos. Pretende-se ainda dar a conhecer uma nova proposta de classificação do traumatismo crânio-encefálico que visa uma caracterização mais completa e individualizada.

Acute upper airway obstruction (AUAO) due to benign thyroid disease is a rare but life-threatening condition. We report a case of an 82-year-old woman with a toxic multinodular goitre who presented to the emergency department with confusion and noisy breathing. Despite being initially stable, she developed progressive stridor and hypoxemia. A neck CT revealed significant tracheal compression due to the goitre. Immediate intubation and corticosteroid treatment were followed by urgent total thyroidectomy and tracheostomy. She was admitted to the ICU for management of laryngeal oedema and rehabilitation. The pathophysiology of AUAO in benign goitres is multifactorial, involving potential haemorrhage, infection, or exacerbation of comorbid respiratory conditions. Early diagnosis through imaging and prompt intervention with thyroidectomy is crucial for survival. Postoperative monitoring for complications like laryngeal oedema and tracheomalacia is essential. This case emphasizes the need for vigilance in managing airway compromise in patients with large multinodular goitres.

There is increasing recognition that point-of-care ultrasound (POCUS), performed by the clinician at the bedside, can be a natural extension of the clinical examination—the modern abdominal “stethoscope” and provides an opportunity to expedite the care pathway for patients with acute gallbladder disease. The primary aims of this study were to benchmark the accuracy of surgeon-performed POCUS in suspected acute gallbladder disease against standard radiology or pathology reports and to compare time to POCUS diagnosis with time to definitive imaging. This prospective single-arm observational cohort study was conducted in four hospitals in Ireland, Italy, and Portugal to assess the accuracy of POCUS against standard radiology in patients with suspected acute biliary disease (ClinicalTrials.govIdentifier: NCT02682368). The findings of surgeon-performed POCUS were compared with those on definitive imaging or surgery. Of 100 patients recruited, 89 were suitable for comparative analysis, comparing POCUS with radiological findings in 84 patients and with surgical/histological findings in five. The overall global accuracy of POCUS was 88.7% (95% CI, 80.3–94.4%), with a sensitivity of 94.7% (95% CI, 85.3–98.9%), a specificity of 78.1% (95% CI, 60.03–90.7%), a positive likelihood ratio (LR+) of 4.33 and negative likelihood ratio (LR) of 0.07. The mean time from POCUS to the final radiological report was 11.9 h (range 0.06–54.9). In five patients admitted directly to surgery, the mean time between POCUS and incision was 2.30 h (range 1.5–5), which was significantly shorter than the mean time to formal radiology report. Sixteen patients were discharged from the emergency department, of whom nine did not need follow-up. Our study is one of the very few to demonstrate a high concordance between surgeon-performed POCUS of patients without a priori radiologic diagnosis of gallstone disease and shows that the expedited diagnosis afforded by POCUS can be reliably leveraged to deliver earlier definitive care for patients with acute gallbladder pathology, as the general surgeon skilled in POCUS is uniquely positioned to integrate it into their bedside assessment.

Endometrial carcinoma is one of the most common gynaecologic malignancies in the western society. Treatment of recurrent disease became more refined, with the study of molecular and hormonal receptors playing a central role. A 76-year-old caucasian woman presented to the emergency department with growing tiredness, and melaena. Past medical history included an endometrioid adenocarcinoma. The patient had undergone a hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymphadenectomy and was disease-free for 2 years. The endoscopy revealed an ulcerated lesion involving the second and third portions of the duodenum. Histopathologic examination confirmed a poorly differentiated adenocarcinoma of endometrial origin. She started palliative chemotherapy, remaining with adequate symptomatic control. Endometrial cancer recurrence typically occurs locally. The liver is the intra-abdominal organ most commonly involved. There are scarce reports of duodenal metastasis of malignancies originated in distant organs. The duodenum remains an uncommon metastization site and is rarely associated with endometrial cancer.

Angiomyolipoma (AML) is a rare benign solid tumor, of mesenchymal origin. Angiomyolipomas can be subdivided, according to their predominant component. The predominance of epithelioid cells characterizes the epithelioid variant (EAML). These express a more aggressive clinical behaviour with a greater potential for malignant transformation. In the absence of specific radiological features, the diagnosis of hepatic EAML depends on the pathological and immunohistochemical study. We present the case of an 80 years old female with a computed tomography (CT) scan showing a hepatic nodule at the transition of segments 5 and 8, and a left kidney nodule previously biopsied and confirmed to be a renal angiomyolipoma. A liver nodule biopsy was performed, whose histology revealed a probable gastrointestinal stromal tumor (GIST). The patient underwent a 5/8 subsegmentectomy and pathology report revealed epithelioid angiomyolipoma. After discussion of the case in the multidisciplinary tumor board, it was decided to perform a left nephrectomy, whose pathology revealed leiomyomatous angiomyolipoma. No further treatment and surveillance on outpatient clinic were decided. Hepatic EAML is a rare lesion that, although mostly benign, can exhibit malignant behavior with distant metastasis and local invasion. Its identification is of paramount importance. The definitive diagnosis is only possible through histological and immunohistochemical analysis. Additional studies are needed in order to establish diagnostic criteria and predictive characteristics of malignancy.

Objective This study aimed to develop and validate a patient-reported outcome measure (PROM) in acute pancreatitis (AP) as an endpoint centred on the patient. Design A PROM instrument (PAtieNt-rePoRted OutcoMe scale in acute pancreatItis, an international proSpEctive cohort study, PAN-PROMISE scale) was designed based on the opinion of patients, professionals and an expert panel. The scale was validated in an international multicentre prospective cohort study, describing the severity of AP and quality of life at 15 days after discharge as the main variables for validation. The COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) methodology was applied. Both the design and validation stages considered the content and face validity of this new instrument; the metric properties of the different items, reliability (reproducibility and internal consistence), the construct, structural and criterion validity, responsiveness and interpretability of this scale. Results PAN-PROMISE consists of a seven-item scale based on the symptoms that cause the most discomfort and concern to patients with AP. The validation cohort involved 15 countries, 524 patients. The intensity of symptoms changed from higher values during the first 24 hours to lower values at discharge and 15 days thereafter. Items converged into a unidimensional ordinal scale with good fit indices. Internal consistency and split-half reliability at discharge were adequate. Reproducibility was confirmed using test–retest reliability and comparing the PAN-PROMISE score at discharge and 15 days after discharge. Evidence is also provided for the convergent-discriminant and empirical validity of the scale. Conclusion The PAN-PROMISE scale is a useful tool to be used as an endpoint in clinical trials, and to quantify patient well-being during the hospital admission and follow-up. Trial registration number NCT03650062