Terapia asistida con vacío y estoma flotante (floating stoma): una nueva forma de tratar un absceso periostomal / Vacuum assisted therapy and floating stoma: S new way to treat a periostomal abscess

Resumen Introducción: Los estomas flotantes se definen como un estoma que no está fijado a la piel de la pared abdominal, esta técnica se ha descrito en cirugía para fístulas entero-atmosféricas y de control de daños. Caso Clínico: Presentamos un reporte de caso de manejo de absceso paraostomal en paciente con antecedente de laparotomía por abdomen agudo, por lo que se decide uso de terapia de presión negativa asociada a estoma flotante, demostrando su utilidad en este tipo complejo de pacientes.

Introduction: Floating stomata are defined as a stoma that is not attached to the skin of the abdominal wall, this technique is described in surgery for entero-atmospheric fistulas and damage control. Clinical Case: We present a case report of the management of paraostomal abscess in a patient with a history of laparotomy due to acute abdomen, it was decided to use negative pressure therapy associated with a floating stoma, demonstrating its usefulness in this complex type of patient.

Intra-abdominal hypertension secondary to chronic diaphragmatic rupture in a dog / Hipertensão intra-abdominal secundária à ruptura diafragmática crônica em um cão

ABSTRACT: Intra-abdominal hypertension (IAH) is the persistent increase of intra-abdominal pressure (IAP) that could be caused by several pathologies. It is capable of promoting organ dysfunction, thereby increasing the mortality rate of human patients. As for cats and dogs, there are still few reports on how this pressure can be monitored and treated as a routine for admitted and hospitalized animals and on its relationship with the mortality of the patients. Therefore, the objective of this paper was to report a case of IAH secondary to chronic diaphragmatic rupture in a dog, which was treated with a temporary abdominal closure (TAC). A bitch was admitted to the veterinary hospital to undergo an elective ovariohysterectomy when it was diagnosed with a diaphragmatic rupture and displacement of the liver and intestinal loops in the chest. After repositioning these structures in the abdominal cavity, tension was observed in the abdomen. A temporary abdominal closure was then performed with a Bogota bag. Immediately after the surgery, the IAP was measured, presenting a value of 15 mmHg, indicating that there was an increase in intra-abdominal pressure. The animal was hospitalized, and IAP was monitored. After 24 hours, IAP was 5.8 mmHg when the Bogota bag was removed, and definitive celiorraphy was performed. The patient showed satisfactory clinical progress and was discharged 72 hours after the surgical procedure. The treatment used for IAH proved to be effective and contributed to the quick and satisfactory recovery of the patient.

RESUMO: A hipertensão intra-abdominal (HIA) é o aumento persistente da pressão intra-abdominal (PIA), podendo ser causada por diversas afecções e caraterizada por promover disfunções orgânicas, aumentando a taxa de mortalidade no homem. Em cães e gatos, ainda há poucos relatos da monitoração dessa pressão e do seu tratamento na rotina dos animais admitidos e internados, e sua relação com a mortalidade dos pacientes. Assim, objetivou-se relatar um caso de HIA secundária à ruptura diafragmática crônica em cão, a qual foi tratada com o fechamento abdominal temporário (FAT). Uma cadela foi admitida no hospital veterinário para realização de uma cirurgia de ovário-histerectomia eletiva, quando foi diagnosticada com ruptura diafragmática com fígado e alças intestinais deslocadas para o interior do tórax. Após reposicionamento dessas estruturas na cavidade abdominal, observou-se tensão no abdômen. Realizou-se então o fechamento abdominal temporário com bolsa de Bogotá. Imediatamente após o término da cirurgia, a PIA foi aferida e seu valor era de 15 mmHg, indicando aumento da mesma. O animal foi mantido internado e sua PIA monitorada. Após 24 horas seu valor era de 5,8 mmHg, quando a bolsa de Bogotá foi removida e realizada a celiorrafia definitiva. O paciente teve evolução clínica satisfatória e 72h após a cirurgia recebeu alta hospitalar. O tratamento utilizado para a HIA se mostrou eficaz, contribuindo para a rápida e satisfatória recuperação da paciente.

Fístula de alto gasto / High output fistula

Se presenta a un paciente de 37 años de edad que acude a nuestro Cuerpo de Guardia politraumatizado, con lesiones torácicas y abdominales, con síntomas y signos sugestivos de fracturas costales múltiples, con hemotórax derecho y hemoperitoneo, corroborado imaginológicamente y en la punción abdominal. Se realiza pleurostomía mínima intermedia y laparotomía exploratoria. Se le encuentran lesiones hepáticas de los segmentos VI, V, VIII y IV, con una profundidad mayor de 3 cm, además, deserosamientos en las asas delgadas intestinales y colon. Se realiza hepatorrafia y empaquetamiento hepático. Posteriormente van apareciendo complicaciones, por lo que tiene que ser reintervenido en máqs de 60 ocasiones. Entre ellas, la aparición de una fístula de alto gasto, que lo llevó a la desnutrición y a la permanencia con el abdomen expuesto durante 7 meses hasta el egreso. Se revisa la literatura correspondiente a estas entidades(AU)

A 37 years-old multi-traumatized male patient went to our emergency service. He had many injures in the thorax and the abdomen, together with symptoms and signs suggestive of multiple costal fractures, with right hemothorax and hemoperitoneum, all of which was confirmed by imaging techniques and by abdominal puncture. Minimal intermediate pleurostomy and exploratory laparoscopy were performed. We found hepatic lesions in the 6th, 5th, 8th and 4th segments, over 3 cm deep; additionally, the loss of serosa from the intestinal ansae and from the colon. Hepatorrhaphy and hepatic packing were also performed. Later on, more complications appeared, so he had to be re-operated more than 60 times. The occurrence of a high output fistula led him to malnutrition and his abdomen remained exposed for 7 months until he was finally discharged from hospital. This paper also presented a literature review on this topic(AU)

Fechamento de laparostomia com descolamento cutâneo-adiposo: uma técnica simples e eficaz para um problema complexo / Skin-adipose tissue detachment for laparostomy closure: a simple and effective technique for a complex problem

OBJETIVO: Descrever uma técnica de fechamento de laparostomia através de descolamento cutâneo-adiposo e os resultados obtidos. MÉTODOS: Entre janeiro de 2003 a outubro de 2008 quarenta pacientes laparostomizados com silo plástico (bolsa de Bogotá) foram fechados usando-se a técnica descrita neste trabalho. Dados foram coletados dos prontuários e da busca ativa após alta hospitalar. RESULTADOS: A maioria dos pacientes eram homens (95 por cento), com trauma por arma de fogo (70 por cento). As médias de ISS e APACHE II foram de 28,78 e 20, respectivamente. Hérnia ventral ocorreu em 81,5 por cento dos pacientes, num intervalo médio de seguimento de 9,2 meses. Aproximadamente 1/3 dos pacientes apresentavam hérnias pequenas e não desejavam corrigi-las quando questionados. Somente dois pacientes estavam insatisfeitos com o procedimento em relação a atividades cotidianas e aspectos estéticos. Não houve óbitos ou fístulas intestinais em decorrência do fechamento. CONCLUSÃO: Embora não represente uma técnica de fechamento mioaponeurótico, o descolamento cutâneo-adiposo é simples, seguro e de baixo custo. É uma boa opção terapêutica para os pacientes laparostomizados, principalmente quando o fechamento da aponeurose não for possível nos primeiros 7 a 10 dias.

OBJECTIVE: To describe a technique of laparostomy closure through cutaneous-adipose tissues detachment and its results. METHODS: From January 2003 to october 2008 forty patients in laparostomy (Bogota bag) were engaged in surgical procedures for closing their open abdomens according to the technique described here. Data were collected from patient records and during active search. RESULTS: The majority of patients was men (95 percent) with gunshot wounds (70 percent). The average ISS and APACHE II scores were 28.78 and 20, respectively. Ventral hernias were found in 81.5 percent of patients with a mean follow-up time of 9.2 months. Approximately 1/3 of patients had small hernias and didn't want to have their hernias closed because they didn't feel any functional or anatomic impediment to support the closure at that time. Only two patients were dissatisfied in relation to daily activities and to the surgical procedure itself. There were neither deaths nor intestinal fistula with this type of closure. CONCLUSION: Although it doesn't represent a technique for fascial closure, it is simple to perform, safe, and with low cost. It is a therapeutic option for patients with open abdomen, especially if closure of the aponeurosis was not possible in the first 7 to 10 days.