Fístula biliopleural postraumática: serie de casos de una complicación muy poco frecuente / Post-traumatic pleurobiliary fistula: a case series of a rare complication

RESUMEN Antecedentes: la fístula biliopleural (FBP) es una complicación poco común del traumatismo torácico-abdominal que se confirma demostrando la presencia de bilis en el líquido pleural. Objetivo: analizar el manejo y tratamiento realizado de las fístulas biliopleurales producto del traumatismo torácico-abdominal abierto y los resultados, comparar con la literatura y proponer algoritmo de tratamiento. Material y métodos: trabajo retrospectivo y descriptivo mediante la revisión de 5688 historias clínicas de pacientes, de los cuales 614 tenían compromiso de la región torácica abdominal, en el Hospital José María Cullen, Santa Fe, Argentina, Centro de Trauma Nivel 1, en el período comprendido entre enero de 2010 y enero de 2016. Se analizaron los datos demográficos, cinemática del traumatismo, diagnóstico, tratamiento y evolución. Resultados: se encontraron 7 casos de FBP. Todos fueron varones jóvenes con traumatismo abierto. Se realizó drenaje pleural como tratamiento inicial en 4 casos; en 2, drenaje pleural y laparotomía exploradora y en 1 toracotomía de urgencia. Dos casos resolvieron solo con el drenaje pleural. En 5 casos se efectuó drenaje de la vía biliar mediante colangiopancreatografía retrógrada endoscópica con esfinterotomía. En 2 de ellos, además, se colocó un stent biliar. Dos de los 5 necesitaron drenaje percutáneo. Por último, 2 casos requirieron toracotomía y 1 de estos, pleurostomía abierta. Todos resolvieron la afección con morbilidad aceptable, sin mortalidad. Conclusión: en la práctica quirúrgica actual, la amplia disponibilidad de endoscopia intervencionista ha mejorado el enfoque invasivo mínimo para el manejo de las fístulas biliopleurales. Se reserva el manejo quirúrgico para aquellas que no responden al tratamiento invasivo mínimo o para las fístulas complicadas, o para ambas.

ABSTRACT Background: Pleurobiliary fistula is a rare complication of thoraco-abdominal trauma that is confirmed by the presence of bilirubin in pleural fluid. Objective: The aim of this study is to analyze the management and treatment performed to patients with pleurobiliary fistula due to penetrating thoracoabdominal injury and their results, compare them with the published literature, and propose a treatment algorithm. Material and methods: For this descriptive and retrospective study, we reviewed 5688 medical records of patients admitted to Hospital José María Cullen, Santa Fe, Argentina, Centro de Trauma Nivel 1 between January 2010 and January 2016; 614 had involvement of the thoracic and abdominal region. The demographic data, kinematics of trauma, diagnosis, treatment and patient progress were analyzed. Results: Seven cases of pleurobiliary fistula were found. All the patients were men with penetrating trauma. Pleural drainage was the initial treatment in 4 cases, 2 patients underwent pleural drainage and exploratory laparotomy and 1 patient underwent urgent thoracotomy. Two cases resolved with pleural drainage alone. Five patients require biliary drainage through endoscopic retrograde cholangiopancreatography with sphincterotomy. Two of these patients also required biliary stenting and 2 also underwent percutaneous drainage. Finally, 2 patients required thoracotomy, 1 of them with open pleurostomy. The fistulae resolved in all the cases with acceptable morbidity. None of them died. Conclusion: In current surgical practice, the wide availability of interventional endoscopy has improved the minimally invasive approach for the management of PBF. Surgical management should be limited to fistulae not responding lo less invasive treatments or to complicated fistulae.

Fístula perianal compleja: Tratamiento con plasma rico en plaquetas / Complex perianal fistula: Treatment with platelet-rich plasma

Paciente masculino con diagnóstico de enfermedad inflamatoria intestinal (colitis ulcerosa), corticodependiente, que consulta en nuestro servicio por fístula perianal compleja con extenso compromiso inflamatorio crónico de la región perianal, el cual fue tratado exitosamente con la aplicación local de plasma rico en plaquetas como única terapéutica. Se presentan los beneficios que se podrían obtener mediante la aplicación de plasma rico en plaquetas autólogo en el tratamiento de este tipo de fístulas. De ese modo se evitan los procedimientos quirúrgicos en un terreno inflamatorio crónico que implican altas tasas de complicaciones y recurrencia, afectando la calidad de vida.

A male patient with a diagnosis of steroid dependent inflammatory bowel disease (ulcerative colitis) sought medical care due to complex perianal fistula with extended chronic inflammation of the perianal region that was successfully treated with platelet-rich plasma as a single therapy. The benefits of autologous platelet-rich plasma for the treatment of this type of fistulas are presented. In this way, there is no need to perform surgery in a chronic inflammatory territory with high rate of complications and recurrence affecting patients' quality of life.

Tratamiento percutáneo del absceso del psoas / Percutaneous drainage of psoas muscle abscess

This article details the treatment of lymphangioma of the face with intralesional bleomycin: with a case report and literature review. Surgical treatment of lymphangioma of the face is a difficult task to achieve, due to close vicinity of the lesion to the facial nerve and possibility of scar tissue formation. Inefficient surgical removals generally will give rise to high recurrence rates because of infiltrative and diffuse extension of the lesion. However, complete cure has been described by non-surgical methods with intralesional bleomycin injection under ultrasonographic guidance. Lymphangioma is a rare congenital malformation of the lymphatic system, frequently seen in the head and neck. Percutaneous sclerotherapy of lymphangioma involves the injection of sclerosing substances into the lymphangioma. This study aims to evaluate the effectiveness of intralesional bleomycin sclerotherapy in the treatment of lymphangioma, and to determine the incidence of complications in the treatment. Intralesional bleomycin therapy was very effective in the treatment of lymphangioma. Bleomycin administered as intralesional injection was found to be safe as there was no lesions complicating or side effects observed in the study.