Left Flank Research Articles

V-024 LAPAROSCOPIC ENHANCED-VIEW TOTALLY EXTRAPERITONEAL RIVES-STOPPA REPAIR (E-TEP RS). FIRST EXPERIENCE AT HOSPITAL UNIVERSITARIO DE CANARIAS

Abstract We present the case of a 55-years-old female with a personal history: high blood pressure, dyslipidemia, without previous abdominal surgeries. Height: 1,65 m; Weight: 62 Kg. BMI: 22,7. Clinical and ultrasound diagnosis of a painful and partially reducible ventral hernia M2 W1 (EHS Classification). It is programmed for hernia correction using the Laparoscopic Enhanced-View Totally Extraperitoneal Rives-Stoppa Repair (e-TEP RS) technique adapted to the hernia defect. Access is made to the left retrorectal space on the left flank, medial to the semilunar line but lateral to the epigastric vessels; dissection of the retrorectal space with a disector balloon on a 5 cm perimeter around the hernia defect; pneumoperitoneum; cross-over manoeuvre connecting the two retrorectal spaces with the medial preperitoneal space; dissection and reduction of the hernia sac; closure of the hernia defect with bearded reabsorbable suture. Implantation of polyvinylidene fluoride (PVDF) macroporous mesh in retrorectal space without using any type of fixation. A retromuscular closed-suction drain is then placed and the place is then desuflatted. The patient is discharged at 12 hours postoperative with in situ drainage, wich was removed in consultation 48 horas after surgery due to null debit. We present the first published case, in our latitude, of a e-TEP RS adapted to the hernia defect. It is a challenging but safe and effective technique as well as practically painless postoperative technique.

V-001 ROBOTIC ETEP WITH TOP DOCK: STEP BY STEP FOR A SAFE PROCEDURE

Abstract Introduction Robotic surgery has evolved in the last few years. Extended total extraperitoneal approach (eTEP) has allowed a better location of the mesh avoiding contact with the bowel. The most important step for this technique is the trocars Positioning in the retrorrectal space. It will depend on the defect localization. Docking can be performed in 3 ways: Inferior (down), lateral and superior (top). The last one represents the most complex. We present a video that explains step by step how to do this technique. Material and methods We considered patients with M3–5W2 and W3 incisional/ventral hernias with a non-injured supraumbilical area. For the retrorrectal dissection, an optic trocar or an expander balloon were used in the left-up quadrant. Afterwards, a 12mm trocar was introduced and the pneumo initiated. At the left flank a 5mm trocar was placed to initiate the crossover with a hook. Subsequently, an 8mm trocar was place in the top midline and next the third robotic trocar at the right up quadrant. Finally, the docking was made. Results Twelve eTEP assisted with robot in a top dock have been performed in a safe way in patients with incisional/ventral hernias. Conclusions The eTEP technique assisted with robot in a top dock position allows a safe access following the steps that we learned in our experience.

V-010 LAPAROSCOPIC TAPP APPROACH OF A GRYNFELLT HERNIA

Abstract Aim To describe our laparoscopic transabdominal preperitoneal approach of a Grynfellt hernia. Material & Methods A female patient 69 years of age with no previous medical history came to our consultation with a chronic right lumbar bulge that produced local pain and discomfort. Preoperative CT scan showed a primary lumbar hernia with a defect estimated at 11cm. Laparoscopic approach seemed feasible and was accepted. Results The patient was placed on a left decubitus with the OR bed at a 45° angle. 3 trocars were used, one slightly lateral of the umbilicus for the camera, and for triangulation a subcostal 5mm and an 11mm trocar in the left flank. We started opening the peritoneum and performing preperitoneal space dissection. The hernia sac was identified and its contents were reduced. We closed the defect using a monofilament absorbable barbed suture with a running stitch. Once the defect was closed, we placed a medium-weight polypropylene mesh in a 3D “taco” configuration covering the defect with sufficient overlap. Both the mesh and the peritoneum closure were done using cyanoacrylate glue. No complications occurred and discharge was the next day. Conclusions Primary lumbar hernias are rare. Symptomatic hernias should be treated as they can lead to pain, discomfort, and a decrease in quality of life. Laparoscopic TAPP is a safe and simple way to access and repair these hernias, allowing an adequate space of dissection that permits the placement of a mesh tension-free with sufficient overlap, with a quick recovery time and minimal morbidity.

80 Case series of juvenile scleroderma at Aga Khan University Hospital, Nairobi

BackgroundJuvenile scleroderma includes a range of conditions presenting with skin fibrosis. It’s classified into two major categories, localized and systemic. Juvenile localized scleroderma (morphea) is limited to the skin and forms majority of pediatric presentations (>95%). Though rare, juvenile systemic sclerosis involves the skin and other internal organs and is associated with a poorer prognosis.ObjectiveTo characterize the clinical profile of two cases of scleroderma at Aga Khan university hospital, Nairobi.MethodsRetrospective review of medical records of two patients with Juvenile scleroderma managed at Aga Khan university hospital, Nairobi.ResultsThe first patient was a 7-year-old boy presenting with joint pains for 2 months, restricted activities and limping. He also had a non-itchy lesion on the right thigh for about 6 years. On examination, there was an 8 by 18 cm, flat, shiny skin lesion with ill-defined margins and skin thickening around it. There were 2 punched out scars from previous skin biopsy sites with latest biopsy showing atrophic epidermis, dermal collagen homogenization with thick sclerosed fibers in keeping with morphea. Pulmonary function tests revealed mild restrictive lung disease. There were no other systems involved on further evaluation. He was started on weekly methotrexate, daily prednisone, daily folic acid and omeprazole to be followed up in clinic.The second case is a 5-year-old girl who presented with 3-year history of inability to walk. Physical examination revealed areas of skin hypopigmentation and hyperpigmentation on the neck and back with active lesions on the left flank and posterior right leg. She had left lower limb atrophy and extreme wasting of thigh and calf muscles, a contracture of the left knee, ankle and limb length discrepancy. Her investigations revealed positive rheumatoid factor, positive antinuclear antibody (ANA), microcytic hypochromic anaemia and skin biopsy with features of morphea. She received six courses of high dose methyl prednisone over six months, weekly methotrexate, daily folic acid, daily prednisone that was tapered off gradually, calcium supplementation and iron supplementation. In addition, she received isoniazid for tuberculosis prophylaxis with pyridoxine. Her management was multidisciplinary involving orthopedics, physiotherapy, occupational therapy, and dieticians. She developed a new skin lesion on the left forearm about five months after initiation of treatment but no worsening of symptoms or other new lesions thereafter.ConclusionJuvenile scleroderma though rare has a high risk of misdiagnosis with delay in initiation of treatment. It is associated with significant morbidity and early diagnosis, treatment and follow up is imperative for good outcomes.

S2875 The Utility of Endoscopic Ultrasound and Fine Needle Biopsy in Diagnosing Remnant Gastric Cancer After Roux-en-Y Gastric Bypass Procedure

Introduction: Roux-en-Y gastric bypass (RYGB) procedure is commonly performed for severe obesity. These patients are at risk of developing remnant gastric cancer. Double-balloon endoscopy (DBE) is typically used to obtain a biopsy. We present two cases of remnant gastric cancer diagnosed using endoscopic ultrasound (EUS). Case Description/Methods: Case 1 is a 76-year-old female status post RYGB who presented with 40-pound weight loss, anorexia and constipation. Labs showed hemoglobin of 6.1 g/dL. Computed tomography (CT) of the chest, abdomen and pelvis revealed hepatic masses and gastric remnant thickening. CA 19-9 was 200,000 U/ml and CEA was 683 ng/dL. Esophagogastroduodenoscopy (EGD) revealed Roux-en-Y gastrojejunostomy with healthy appearing mucosa and a normal jejunum. Colonoscopy showed internal hemorrhoids. Liver biopsy was inconclusive. Concern for remnant gastric cancer, in light of no obvious primary, prompted transgastric EUS guided fine needle biopsy (FNB) of the remnant pouch which confirmed gastric adenocarcinoma.Case 2 is a 49-year-old female status post RYGB who presented with left flank pain,12-pound weight loss and fevers. Labs showed hemoglobin 9 g/dL. CT of the abdomen showed wall thickening involving the gastric pouch and gastric remnant. CEA was 96.6 ng/dL and CA-125 was 348.7 U/ml. EGD revealed a small gastric pouch, gastrojejunal anastomosis characterized by polypoid appearing lesions which were biopsied and found to be benign, and a normal jejunum. Colonoscopy showed inflammation in the cecum and transverse colon and biopsies revealed adenocarcinoma consistent with metastatic signet ring cell carcinoma. Transjejunal EUS guided FNB of the gastric remnant confirmed signet ring cell adenocarcinoma. (Figure) Discussion: EUS is a valuable tool for tissue acquisition especially because DBE has challenges of high operator dependence and long procedure times. Case reports have described EUS guided placement of lumen-apposing metal stents (LAMS) to create a conduit into the gastric remnant to obtain biopsies. However, LAMS are highly operator dependent and carry complications of stent migration, bleeding, infection and perforation. The EUS guided FNB technique is shown in image 1. There were no complications intra or post operatively. Our cases show that EUS with a trans-gastric or trans-jejunal approach provides a less invasive approach that is more operator-friendly, time saving and yields adequate tissue acquisition.Figure 1.: EUS images. A, Case 1: Transgastric view of thickened gastric remnant. B, Case 1: Fine needle biopsy of gastric remnant wall. C, Case 2: Transjejunal view of thickened gastric remnant. D, Fine needle biopsy of gastric remnant wall.

Almost slipped through the crack: Pediatric patient with bilateral slipped rib syndrome and twelfth rib syndrome of the eleventh ribs

Slipped rib syndrome is a rare disorder in which there is hypermobility of the anterior false ribs, resulting in the tips of the ribs moving or slipping under the superior rib. Alternatively, twelfth rib syndrome is caused by irritation of the twelfth intercostal nerve related to the hypermobility of the twelfth rib. In this report, we present a case of a 15-year-old male who presented with debilitating pain in the left posterior flank that persisted despite multiple medications and physical therapy. He was diagnosed with left-sided slipped rib syndrome and twelfth rib syndrome of the eleventh rib which was treated with eleventh rib excision. Less than one year later he developed right-sided pain and was ultimately diagnosed with right-sided slipped rib syndrome and twelfth rib syndrome of the eleventh rib for which he underwent right ninth and tenth costal cartilage excision and right eleventh rib excision. The patient then had complete resolution of his pain. A delineation between slipped rib syndrome and twelfth rib syndrome is important since they are both relatively rare and often misdiagnosed. Our case report is significant since our patient had both of these rare diseases bilaterally which to our knowledge has not been previously published. • Slipped rib syndrome and twelfth rib syndrome are rare causes of chest and back pain. • Increased awareness will decrease unnecessary studies and pain for these patients. • Our patient had bilateral SRS and twelfth rib syndrome, which has not been not previously described. • Resection of the affected rib with cryoablation of the intercostal nerve is a safe and effective treatment.

Zur Gründung des 140 m hohen Staudamms Kühtai im Längental

AbstractKühtai Dam is an embankment dam with a central earth core that is founded on rock. The rock surface is treated by shaping, adding dental concrete and, finally, grouting. A large excavation was required to expose the rock in the earth core foundation. Before starting the excavation, the Längentalbach stream had to be diverted. The upstream and downstream shells of Kühtai Dam are founded on the remaining overburden. Under the earth core, an inspection tunnel is located along the dam axis. The tunnel serves to accommodate measuring equipment and decouple fill and grout curtain works in terms of sequence of construction. In deviation from the tender project, the inspection gallery on each side of the valley is constructed as a combination of two conventional adits and two raise‐boring shafts. To connect the adits and shafts, reinforced concrete structures are situated at half dam height, on which the earth core is founded directly similar to an inspection gallery in trench type. On the one hand, this adjustment is the result of a geological fault detected during the preliminary excavation works in 2020. The fault crosses the core footprint in the orographic left flank of the valley. On the other hand, the subdivision of the two long conventional shafts will eliminate the construction time constraint resulting from the requirement to not start grouting in the dam foundation until the conventional tunnelling below the dam has been completed.

E-CIGARETTE OR VAPING PRODUCT USE ASSOCIATED LUNG INJURY: A DIAGNOSTIC DILEMMA

E-CIGARETTE OR VAPING PRODUCT USE ASSOCIATED LUNG INJURY: A DIAGNOSTIC DILEMMA

ATYPICAL PRESENTATION OF MYCOBACTERIUM CHIMAERA PNEUMONIA FOLLOWING TRANSESOPHAGEAL ECHOCARDIOGRAPHY

ATYPICAL PRESENTATION OF MYCOBACTERIUM CHIMAERA PNEUMONIA FOLLOWING TRANSESOPHAGEAL ECHOCARDIOGRAPHY

Papillary follicular variant thyroid cancer in a malignant struma ovarii: a report of a rare case.

A 33-year-old female presented in 2013 with left flank pain. Ultrasound and MRI pelvis showed a complex mass 9 × 7 cm arising from the left ovary suggestive of ovarian torsion. She underwent a laparoscopic cystectomy, but the patient was lost to follow-up. Three years later, she presented with abdominal distension. Ultrasound and CT scan revealed a solid left ovarian mass with ascites and multiple peritoneal metastasis. Investigations showed elevated CA 125, CA 19-9. Ovarian malignancy was suspected. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy on November 2016. The histopathology confirmed a well-differentiated thyroid cancer of ovarian origin with features of a papillary follicular variant without evidence of ovarian cancer and the thyroglobulin (Tg) level was elevated, more than 400 consistent with the diagnosis of malignant struma ovarii. The follow-up post-surgery showed normalization of CA 125, CA 19-9 and Tg. The patient underwent total thyroidectomy on January 2017. The histology was benign excluding thyroid cancer metastases to the ovary. She was started on thyroxine suppression, following which she received two ablation doses 131iodine (131I) each 5.3 GBq. The Tg remains slightly elevated at less than 10. 131I WBS showed no residual neck uptake and no distant avid metastasis. She was planned for molecular analysis which may indicate disease severity. We describe a case of malignant struma ovarii with widespread metastatic dissemination and a good response to surgery and 131I treatment without recurrence after 5 years of follow-up. The Tg remains slightly elevated indicating minimal stable residual disease. Malignant struma ovarii is a rare disease; diagnosis is difficult and management is not well defined. Presentation may mimic advanced carcinoma of the ovary. Predominant sites of metastasis are adjacent pelvic structures. Thyroidectomy and 131iodine therapy should be considered. The management should be similar to that of metastatic thyroid cancer.

S3025 Hepatic Sarcoidosis Presenting as Decompensated Liver Cirrhosis

Introduction: Sarcoidosis is a disorder characterized by the formation of non-caseating granulomas in multiple organ systems. While pulmonary manifestation is the most common presentation, hepatic involvement can be seen in many patients. Most patients with liver involvement are asymptomatic; however, some can present with symptoms of liver injury. The presentation of hepatic sarcoidosis can resemble many other disease processes. Since definite diagnostic criteria have not yet been formalized for hepatic sarcoidosis, it can often be challenging for providers to make a prompt diagnosis. Case Description/Methods: We present the case of a 36-year-old female who was evaluated for generalized abdominal pain and left flank pain. On presentation, labs were notable for calcium at 13 mg/dl, ionized calcium at 1.62 mmol/l, PTH at 8 pg/ml, 1,25-dihydoxyvitamin D at 96.4 pg/ml, alkaline phosphatase at 192 IU/L, AST at 51 IU/L and ALT at 47 IU/L. Eight months prior, the patient was admitted to an outside hospital in the setting of hematemesis. EGD with variceal banding was performed, and she was diagnosed with cryptogenic liver cirrhosis. CT A/P demonstrated marked heterogeneity of the liver. MRI of the abdomen showed mild hepatosplenomegaly and “diffuse small areas of altered signal intensity throughout the liver suspicious for diffuse hepatic metastatic disease” (Figure A). The patient just had her first visit with an oncologist prior to her presentation to our hospital. Her physical exam was notable for hepatomegaly, abdominal distension and RUQ tenderness. Her hypercalcemia was treated with fluids. Infectious and autoimmune workup came back negative. Different tumor markers including CA 19-9, CA 27-29 and CA 125 were normal. Liver biopsy showed hepatic parenchyma with numerous non-necrotizing granulomas and associated fibrosis. IL-2R receptor-serum came back elevated at 2916.1 pg/ml. The patient was then started on 20 mg prednisone daily for treatment of hepatic sarcoidosis. Discussion: Hepatic sarcoidosis can have a wide spectrum of clinical presentation, ranging from incidental finding to end-stage liver disease. When a patient is diagnosed with a new hepatic disease, keeping hepatic sarcoidosis on the differential is very important. In case of hepatic sarcoidosis, assessing symptoms of liver involvement and biochemical evidence of cholestasis is crucial. While observation is indicated for asymptomatic liver disease, corticosteroids and/or ursodeoxycholic acid are the first line agents for symptomatic disease.Figure 1.: Hypointense liver lesions on MRI, initially presumed suspicious for diffuse hepatic metastatic disease, later confirmed to be sarcoid lesions.

Laparoscopic Approach in Large Rare Adrenal Ganglioneuroma

Introduction: Adrenal ganglioneuroma is an extremely rare and benign tumor comprising Schwann cells and ganglion cells. Adrenal ganglioneuroma is usually hormonally silent and tends to be discovered incidentally on imaging tests. Here, we present a case of a 39-year-old man with adrenal ganglioneuroma who underwent laparoscopic left adrenalectomy.Case Presentation: a 39-year-old man was admitted to our department with left flank pain after he recovered from Covid-19. He had no symptoms of nausea, vomiting, headache, diarrhea, palpitation, or chest distress, and there was no lack of appetite or weight loss. He denied any medical conditions, such as hyperaldosteronism, hypercortisolism, and hypertension. On further examination with contrast-enhanced CT identified a hypo-isodense mass in the left adrenal gland, measuring 4.8 x 4.4 x 5.0 cm, and spotty dense calcification in the middle of the mass. All functional laboratory evolution showed negative including urinalysis and serum electrolyte. Because the non-functioning suprarenal tumor was presumed to be benign, a laparoscopic approach was planned for definitive extirpation of the left adrenal gland. CT triple-phase whole abdomen was done before the procedure which showed contrast-enhanced identified an isodense mass with 43 HU in the left adrenal gland, measuring 4.8 x 4.4 x 5.0 cm with absolute washout of 49.3% and relative washout of 30.7%. Laparoscopic left adrenalectomy was performed. The patient underwent successful laparoscopic extirpation of the left adrenal gland. The postoperative pathology revealed a 7.0 x 6.0 x 3.0 cm encapsulated tumor with a firm texture. Microscopically, the tumor showed a mixture of mature ganglion cells and fascicles of Schwann cells. Adrenocortical cells were found near the capsule.Conclusions: Even though there have been some guidelines for the diagnosis of Adrenal ganglioneuroma, pre-operative misdiagnoses are still frequent. We recommend that complete operative resection should be considered once malignancy cannot be excluded by pre-operative evaluation. Laparoscopic adrenalectomy is a reasonable option at least for tumors < or = 4.5 cm. Adrenal ganglioneuroma can be successfully excised laparoscopically with an appropriate and experienced surgeon.

Renal primitive neuroectodermal tumor. The first case series from Syria.

Primitive neuroectodermal tumor (PNET) mainly arises from soft tissues of the extremities such as humerus, femur, C tibia. It rarely arises from kidney; less than 200 cases have been reported in the literature. The clinical presentation and radiography findings are not specific. Here we first report two cases of renal primitive neuroectodermal tumor in Syria.the first patient was 26-year-old- female that presented to urology clinic complaining of right flank pain. Ultrasonography of the abdomen showed a large mixed heterogeneous mass in the right kidney with no hemorrhage or calcification and MSCT of abdomen and pelvis demonstrate a mixed well-demarcated heterogeneous mass measuring (74*117) mm in the right kidney right radical nephrectomy was performed.The second patient 19-year-old-male presented with left flank pain. Ultrasonography of the abdomen showed mixed large mass involving the left kidney, with unmarked border. The CT of the abdomen and pelvis demonstrating a (30*110*90) mm left renal mass and periaortic lymphadenopathy measuring (45*28) mm. The patient underwent Left radical nephrectomy with periaortic lymphadenectomy dissection. The final diagnosis for both cases was Renal PNET based on microscopic and immunohistochemistry examination.In patient with suspected renal mass in the radiographic images, the diagnosis of renal primitive neuroectodermal tumor should be kept in the mind despite its rarity. The final diagnosis is done by histopathological study in association with immunohistochemical examination.

Man With Left Flank Pain

An 81-year-old man with a peripheral vascular disease presented to the emergency department with acute left flank pain for several hours that resolved after oral analgesia. He was hemodynamically stable, and his abdomen and flank were soft and nontender. Laboratory tests included an acutely increased creatinine level of 1.5 mg/dL. A bedside ultrasound demonstrated a hyperechoic left kidney with perinephric fluid and an abdominal aortic aneurysm of 8 cm (Figure 1). Abdominal computed tomography demonstrated an abdominal aortic aneurysm with aorto-left retroaortic renal vein fistula and secondary renal vein infarction with decreased parenchemal enhancement and perinephric fluid (Figure 2).

Combined extract of heated TC1, a heat-killed preparation of Lactobacilluscasei and alpha-galactosyl ceramide in a mouse model of cervical cancer

BackgroundNowadays, cancer is the leading cause of death among threats to humanity, necessitating prompt action and preparation. Cervical cancer is one of the most common cancers in women and is currently treated with surgery, radiation, chemotherapy, and immunotherapy, among other treatments. Current oncology approaches focused on the simultaneous development of safe and effective cancer multi-agent therapies. The present study aimed to evaluate the effects of a combined extracts of heated TC1, a heat-killed preparation of Lactobacilluscasei, and alpha-galactosyl ceramide (α-GalCer) in a mouse model of cervical cancer.Material and methodsCervical cancer in the mouse model was prepared by TC1 cells subcutaneous injection into the left flank of female C57BL/6 mouse aged 6–8 weeks (n = 80). After the appearance of the palpable tumor, the mice with cervical cancer were randomly devoted to 8 (ten-member) groups. The mice in some groups were treated with PBS, TC1 cell extract, L. casei extract, α-GalCer, and a combination of the mentioned treatments. Then, they were evaluated the splenocytes proliferation, lactate dehydrogenase production and nitric oxide. Moreover, IL-4, IFN-γ, and TGF-β cytokine levels of splenocytes supernatant the mice were measured. In all evaluations, a statistical difference of less than 0.05 (P ˂ 0.05) was considered as a significant level.ResultThe findings revealed that the combination therapy group (heated TC1 cell and L. casei extracts with α-GalCer) significantly increases the splenocytes proliferation (MTT) (0.358 ± 0.04 OD), LDH production (45.9 ± 2.3 U/L), NO rate (38.4 ± 2.8 µM), and IFN-γ cytokine level (46.6 ± 3.7 pg/ml) (P < 0.05). Also, observes a significantly reduces the production of IL-4 (11.6 ± 2.5 pg/ml) and TGF-β cytokines levels (7.8 ± 2.5 pg/ml) (P < 0.05) in comparison to the control group.ConclusionThe study showed that combination therapy of L. casei and α-GalCer is an efficient treatment for cervical cancer in the mouse model.

Thermoregulatory reactions of female buffaloes raised in the sun and in the shade, in the climatic conditions of the rainy season of the Island of Marajó, Pará, Brazil.

Buffaloes are well-adapted to hot, humid climates and muddy terrain, however they show signs of thermal discomfort when exposed to direct sunlight due to their specific structural features such as dark skin, small number of sweat glands/skin area and thick skin. Epidermis layer of the skin, making heat dissipation difficult. The study aimed to evaluate the thermal comfort of female buffaloes raised in traditional and silvopastoral systems, on the island of Marajó, Pará, during the rainy season of the year. The experiment was carried out in Cachoeira do Arari, Retiro Grande, Marajó, Pará (00°55'37.814424”S 48°43'48.143060”W). Twenty female Murrah buffaloes, aged between 2 and 3years and average weight of 282 ± 29 kg, were used. They were fed on pasture and divided into two groups: WS group (with shade) and NS group (without shade). The WS group (n = 10) remained grazing in a silvopastoral system, with access to the shade of red Jambeiro (Syzygium malaccense) trees. The NS group (n = 10) was kept in grazing, in a traditional system, without access to the shade of trees or shades. The physiological variables rectal temperature (RT), respiratory rate (RR) and body surface temperature (BST) (forehead, left side of the thorax and left flank) were measured at 6:00, 10:00, 14:00, 18:00, and 22:00 h. At the same times, data on air temperature, relative air humidity, wind speed (WSP), solar radiation (SR) and Temperature and Humidity Index (THI) were also recorded. THI, WSP and SR were higher at 14:00 h (P < 0.05). At 10:00, 14:00, and 18:00 h there was difference of RT between treatments (P < 0.05), where animals of the NS group had the highest values. In the NS group, the highest value of RT was observed at 14:00 h (39.38 ± 0.43°C), when THI and SR were higher. At 10:00 and 14:00 h, BST was higher in the NS group (p < 0.05), of 34,55 ± 1.03 and 35.35 ± 1.51°C, respectively, and both groups had the highest value of BST at those same times. There was difference of the RR between treatments at 10:00 h and 14:00 h (p < 0.05), where the highest values were found in the NS group (33.71 ± 7.58 e 50.40 ± 18.41 mov./min., respectively). Even in the rainy season of the year, the climatic conditions of Ilha do Marajó are unfavorable to the welfare of buffaloes, especially at 2:00 pm, when the SR is higher. Thus, the use of the system with access to shade, such as silvopastoral, is recommended, in order to provide greater thermal comfort to animals and improve their productivity.

Clinical Case: Treatment for a Sarcoid in a Quarter-Mile Horse Using a Citric Extract Adsorbed to a Titanium Nano-Particles

In a quarter-mile horse, a tumor-like mass was presented on the left flank, with a diagnosis of sarcoid. At the beginning, cures were carried out twice a day with natural water, hydrogen peroxide and coumaphos with propoxur as mosquicide and larvicide, observing that there was no favorable regeneration of the tissue and after the surgical removal of the tumoral mass. Treatment with NANOCIT was initiated on the 16th after surgery, a spray with citrus extracts adsorbed to a titanium nanoparticles (NANOCIT) at 12 hours intervals for 15 days, treatment wit NANOCIT promoted an abundant granulation tissue with a termination of the inflammatory process with good cicatrization.

Interventional Management of a Rare Combination of Nutcracker and Wilkie Syndromes.

Nutcracker and Wilkie syndromes are rare mesoaortic compression entities, and their association is even less common. Data on interventional treatment of these pathologies are still scarce, but results from limited case series are encouraging. We report the case of a previously healthy 45-year-old woman diagnosed with nutcracker and Wilkie syndromes who presented with macroscopic hematuria, intermittent pain in the left flank and hypogastric region, postprandial nausea, and unexplained significant weight loss. A successful endovascular approach with stent implantation in the left renal vein was performed, but the stent migrated toward the left kidney, and this acute complication was managed through an interventional strategy as well. At the three-month follow-up, the patient described a marked improvement in all symptoms, except for the macroscopic hematuria. As it was our strong belief that the approach was efficient, we further investigated the “hematuria”, which eventually led to the diagnosis of endometrial carcinoma. A hysterectomy and bilateral adnexectomy were planned, and chemoradiotherapy was initiated with the goal of preoperative tumor reduction. To our knowledge, this is the first reported case in which both Wilkie and nutcracker syndromes were effectively treated by stent implantation in the left renal vein, complicated with very early stent migration due to inadequate apposition to the less compliant venous lumen. The treatment of the duodenal compression was indirectly included in the stenting of the left renal vein, as reclaiming the venous lumen widened the aortomesenteric angle. The aim of this review is to discuss our center’s transcatheter experience with these rare disorders and explore the literature in order to establish the benefits and limitations of such an approach.

Anterior Renal Nutcracker Syndrome in an Older Adult Treated with Endovascular Stenting

Anterior nutcracker syndrome occurs when the left renal vein is compressed between the abdominal aorta and the superior mesenteric artery. A 71-year-old woman presented to hospital with sudden-onset intense lower abdominal pain with radiation to the left flank region. Her lab work was significant for hemoglobin 9.8 G/DL (11.7 - 15.0 G/DL), creatinine 1.52 mg/dL (0.50 - 1.10 mg/dL) and microscopic examination of the urine contained red blood cells. Computed tomography scan of the abdomen &amp; pelvis with contrast showed left renal vein narrowing as it crosses between the superior mesenteric artery and the aorta, consistent with nutcracker sydnrome. The patient underwent a venogram study alongside intravascular ultrasound and was treated with left renal vein wall stenting and venoplasty. She tolerated the procedure well and was successfully discharged on daily anticoagulation with rivaroxaban for one month with close follow-up.

248.8: Mycobacterium tuberculosis Colitis and Cytomegalovirus in A Renal Transplant Recipient: An Infrequent Association

Introduction: Chronic diarrhea, infectious or inflammatory, is a frequent cause of consultation in transplant recipients. Immunosuppressants are the most common reason, but microorganisms like cytomegalovirus (CMV), clostridium difficile, campylobacter, are often reported. Tuberculosis can occur, but it has a low prevalence, described between 0.3 and 1.7%. Method: We described a 32-year woman with a history of membranoproliferative glomerulonephritis, recipient of a deceased-donor kidney transplant 12 years ago. She received basiliximab and steroids as induction therapy and maintenance with tacrolimus, mycophenolate and deflazacort. She consulted with a 7-day history of liquid diarrhea, no blood, nor mucus with abdominal pain, nausea, and fever up to 39°C. She manifested a 10kg loss of weight in a 6 month-period with no other symptoms. Upon admission, she had tachycardia, mild abdominal pain in left flank. Blood workup showed normal leukocytes and platelets, absolute lymphocyte count of 0.8x103/ L, hemoglobin 8.9g/dL, creatinine 1.51mg/dL, high C-reactive protein, and low level of albumin. Low iron, TSAT and high ferritin level. Normal folic acid and vitamin B12. Coproscopic showed blood, no leukocytes. Blood cultures, molecular panel identification of multiple gastroenterology pathogens (filmarrayTM), VIH, viral load with transcriptase-polymerase-chain-reaction (PCR) in blood for CMV were negative. Chest radiography was normal. Contrast abdominal tomography showed thickening and enhacement of the walls of the cecum, hepatic flexure, ileocecal valve and distal ileum. In ascending colon, a 4cm decreased of the lumen was seeing. Multiple round nodes smaller than 10mm after contrast were observed. Total colonoscopy showed colitis in transverse and left colon with 80% stenosis of the lumen. Biopsy documented active chronic colitis with a marked ulcerative component. No microorganisms, dysplasia or malignancy were observed. Real time-PCR was processed for CMV in colonic tissue and PCR for mycobacterium tuberculosis (MT) both reported positive. Co-infection with intestinal CMV and MT was diagnosed. She was treated with valganciclovir for 4 weeks and tetraconjugate with isoniazid(H), rifampicin(R), pyrazinamide(Z), ethambutol(E) and pyridoxine. During treatment, presented elevated transaminases and uric acid attributed to hepatotoxicity for H. It was switched to moxifloxacin with improved in hepatic profile. Moxifloxacin, R and Z were continued for 9 months. The patient had resolution of the diarrhea, recovery of weight, anemia and renal function. Conclusion: CMV is a common etiological agent in kidney transplant recipients with diarrhea, co-infection with other microorganisms, such as, MT can worsen the clinical course and without treatment can lead to death. Having a high index of suspicion is essential. A rigorous diagnostic approach is necessary and performing PCR on tissue can contribute to allow early diagnosis and timely treatment.