Nodular lesions of the liver in multiple myeloma

An 83-year-old woman was admitted because of asthenia, weight loss and abdominal pain. She had been diagnosed with MGUS IgGk twenty years earlier and the monoclonal protein levels had remained persistently stable. At admission, physical examination showed pallor, marked hepatomegaly (5 cm below th

Laparoscopic treatment of giant circumferential leiomyoma of the distal esophagus

Introduction: Leiomyomas are rare esophagus tumors, with 0.4-1% incidence of all esophagus tumors, being more frequent in medium and distal portions1. Only 5% grow to the point of being called giant tumors, measuring more than 10cm2. Symptoms usually begin on tumors equal to or bigger than 5cm. Objectives: The following case objectifies reporting a new therapeutic course of action to giant leiomyomas of distal esophagus. Case Report: VCA, female, 38 years old, presented retrosternal oppression for 4 months. Having realized a computed tomography (CT) on another service 5 days ago which demonstrated a tumor injury on the distal esophagus and suggestive of leiomyoma. Patient was submitted through endoscopy exam 4 months ago, for complaint of heartburn and mild dysphagia. It was determined a hiatal hernia of 2cm and mild gastritis. Patient was submitted to complete excision of tumor without mucosal lesion and reconstruction of the external muscular wall, by the video laparoscopic method. Hiatoplasty and partial esophagogastrogemorplication were associated. The anatomic pathological examination confirmed the leiomyoma, with 10x5x2cm. Patient evolved clinically in the long term without the appearance of the heartburn or dysphagia. The patient underwent contrast examination of the esophagus after 6 months and endoscopy and tomography for the following 4 years, all normal. The classic treatment of giant leiomyomas larger than 10cm, includes thoracotomy with esophagectomy. Considering that in 80% of the cases it is found in the middle and lower thirds of the esophagus, the videolaparoscopic approach by transhiatal route becomes possible3. The reconstruction of the external muscular layer is important to prevent a possible prolapse of the mucosa1. Also, the realization of the fundoplication in addition to avoiding the gastroesophageal reflux, allows the suture area of the esophageal muscular wall to be covered, increasing the safety in the treatment4. In services with experience in the surgical treatment of diseases of the gastric esophagus transition through the videolaparoscopic method, it is possible to perform with adequate safety the surgical treatment of the tumor lesions of the distal esophagus. The method provides the patient with greater postoperative comfort and prompt clinical surgical recovery

フランス キギョウ ノ ケイエイ センリャク ト リスク マネジメント

博士(商学)大阪市立大

Pyloric Exclusion with Ovesco (Over-the-scope-clip) Device for Jejunal Fistula in Duodenal Obstruction of Malignant Etiology

Se reporta el caso de un hombre de 25 años con diagnóstico de tumor de células germinales no seminomatoso que ingresó a urgencias por cuadro clínico de dolor abdominal difuso asociado con distensión y múltiples episodios eméticos. Ante la sospecha clínica de obstrucción intestinal se realizó una tomografía abdominal contrastada que mostró una obstrucción en la tercera porción duodenal por compresión extrínseca ocasionada por múltiples conglomerados retroperitoneales. Se decidió el tiempo quirúrgico para una derivación gastrointestinal en la que se realizó una gastroyeyunoanastomosis por técnica convencional; hacia el quinto día posoperatorio presentó un deterioro clínico dado por episodios febriles, dolor abdominal y taquicardia. Se realizó una nueva tomografía abdominal que reportó una colección intraabdominal en el flanco izquierdo de 12 x 12 x 5 cm secundaria a proceso fistuloso yeyunal, se realizó un manejo de la colección con drenaje percutáneo por radiología intervencionista y alojamiento de catéteres de drenaje, y se realizó una esofagogastroduodenoscopia con el fin de ejecutar una técnica de exclusión pilórica con dispositivo Ovesco (over-the-scope) como manejo de la fístula yeyunal, con la que se obtuvo éxito técnico. Durante el posoperatorio se realizó como seguimiento una radiografía de vías digestivas que confirmó la no continuidad pilórica con adecuada permeabilidad de la gastroyeyunoanastomosis, y una tomografía abdominal contrastada que mostró una disminución de la colección intraabdominal sin extravasaciones del medio de contraste. El desenlace favorable de este caso sugiere la utilidad del dispositivo Ovesco en casos de fístulas del tracto gastrointestinal proximal, sobre todo en aquellos pacientes con múltiples comorbilidades o mal estado general que se favorecen de procedimientos mínimamente invasivos que disminuyan el riesgo de desenlace fatal.Q4Pacientes con Tumor de células germinales no seminomatosoA 25-year-old man diagnosed with a non-seminomatous germ cell tumor was admitted to the emergency department for diffuse abdominal pain associated with bloating and multiple emetic episodes. Due to the clinical suspicion of intestinal obstruction, a contrasted abdominal tomo-graphy was performed, showing an obstruction in the third duodenal portion resulting from extrinsic compression caused by multiple retroperitoneal conglomerates.Surgical time was scheduled for a gastric bypass surgery where gastrojejunostomy was performed using conventional technique. On the fifth postoperative day, he presented clinical deterioration due to febrile episodes, abdominal pain, and tachycardia. A new abdominal tomo-graphy was performed, reporting an intra-abdominal collection of pus on the left flank of 12 x 12 x 5 cm secondary to the jejunal fistula process. Hence, percutaneous drainage management of the collection was performed by interventional radiology and drainage catheter placement. In addition, an EGD was performed to conduct a pyloric exclusion technique with an Ovesco (over-the-scope-clip) device for managing the jejunal fistula, which was technically successful.A gastrointestinal tract X-ray was performed as a follow-up during the postoperative stage, showing no pyloric continuity with adequate patency of the gastrojejunostomy. In addition, a contrasted abdominal CT scan showed a decrease in the intra-abdominal collection without extravasation of the contrast medium. This case outcome suggests the Ovesco device may be helpful in proximal GI fistulas cases, especially in patients with multiple comorbidities or poor general conditions who may benefit from minimally invasive procedures decreasing the risk of fatal outcomes.https://orcid.org/0000-0002-3503-8493Revista Nacional - IndexadaCN

De la gestion de la saisonnalité et des destinations touristiques vers une industrie touristique diversifiée et performante : Cas d’Agadir

This research study will present a theoretical synthesis from the literature as well as a quantitative study conducted on the impact of seasonality on tourist activity for the destination Agadir, Morocco and its performance. Based on a questionnaire carried out with 100 tourists (national and international) of the Agadir destination in order to know the time of year in which tourists visit the city of Agadir, to know the reasons why tourists choose this period, determine the average length of their stay, identify the reasons for their trips, and know the travel behavior of tourists visiting this destination (transport, activities, expectations, motivations, etc.). As well as an interview guide intended for professionals in the tourism sector of the city of Agadir, where we have targeted tourism stakeholders including accommodation establishments, travel agencies, restaurants, bazaar shops and others. By interviewing a sample of twenty-five of the most important players in this destination, from all tourism professions combined, knowing that the objective is to identify whether they suffer from a seasonality problem or not, to identify their periods of the most profitable year, to measure the impact of this seasonality phenomenon in terms of income, to know the communication channels that these professionals use and finally to identify the means used to deal with this seasonality during the low season and to make the Agadir destination efficient throughout the year. The results of this quantitative study will constitute the basis on which we will base our discussions and our recommendations in order to act on the tourism sector.   Keywords: Tourism, seasonality, performance, tourism marketing, tourist destination. JEL classification: M21 Paper type: Empirical ResearchCette étude de recherche va présenter une synthèse théorique issue de la littérature ainsi qu’une étude quantitative menée sur l’impact de la saisonnalité sur l’activité touristique pour la destination Agadir, Maroc et sa performance. En s’appuyant sur un questionnaire réalisé auprès de 100 touristes (nationaux et internationaux) de la destination Agadir  afin de connaitre la période de l’année  dans laquelle les touristes visitent la ville d’Agadir, savoir les raisons pour lesquelles les touristes  choisissent cette période, déterminer la durée moyenne de leur séjour, identifier  les motifs de leurs voyages, et de connaître le comportement de voyage des touristes visitant cette destination (Transport, activités, attentes, motivations...). Ainsi qu’un guide d’entretien destiné aux professionnels du secteur touristique de la ville d’Agadir, où nous avons ciblé les acteurs du tourisme, dont des établissements d’hébergement, des agences de voyages, des restaurants, des boutiques bazars et d’autres. En interrogeant  un échantillon de vingt-cinq des acteurs les plus importants de cette destination, de tous métiers de tourisme confondus sachant que l’objectif est de dégager si ces derniers souffrent d’un problème de saisonnalité ou non, d’identifier leurs périodes de l’année les plus rentables, de mesurer l’impact de ce phénomène de  saisonnalité en matière de revenus, de connaitre les canaux de communication auxquels ces professionnels font recours et de dégager finalement les moyens utilisés pour faire face à cette saisonnalité durant la basse saison et de rendre performante la destination Agadir pendant toute l’année. Les résultats de cette étude quantitative constitueront la base sur laquelle nous allons fonder notre discussion et nos recommandations afin d’agir sur le secteur touristique.   Mots clés: Tourisme, saisonnalité, performance, marketing touristique, destination touristique. Classification GEL : M21 Type de papier : recherche empiriqu