Trauma abdominal contuso por golpe con manubrio de bicicleta: evaluación y tratamiento / Blunt abdominal trauma due to handlebar injury

INTRODUCCIÓN: Los accidentes en bicicleta son una causa frecuente de trauma abdominal contuso en pediatría. En Chile no existen publicaciones científicas que traten sobre las lesiones abdominales por manubrio de bicicleta, su presentación y manejo. OBJETIVO: Describir tres casos clínicos de trauma abdominal contuso provocados por manubrio de bicicleta en niños, ilustrar las distintas lesiones observadas, sus formas de presentación y manejo. CASOS CLÍNICOS: 1) Paciente masculino, 11 años, consulta tras golpe con manubrio de bicicleta en epigastrio; en la Tomografía Computada (TC) de abdomen y pelvis se describió neumoretroperitoneo. Se realizó laparotomía exploradora, reparándose una perforación duodenal. 2) Paciente masculino, 14 años, consulta tras golpe en el hipocondrio izquierdo con el manubrio de la bicicleta; en la TC se evidenció fractura esplénica con múltiples laceraciones. Por la presencia de sangrado activo se trató con angioembolización, lográndose resolución de la lesión y viabilidad del órgano luego de 6 semanas de seguimiento. 3) Paciente masculino, 9 años, ingresó tras sufrir golpe con manubrio de bicicleta en el hipocondrio derecho. En TC se observó una laceración hepática, que fue manejada de forma expectante, con resolución de la lesión luego de 8 semanas de seguimiento. Todos los pacientes tuvieron una evolución favorable. CONCLUSIÓN: El trauma abdominal contuso por golpe con manubrio de bicicleta puede ser potencialmente grave en pacientes pediátricos, pudiendo afectar órganos sólidos y vísceras huecas. El manejo no quirúrgico cada vez es más utilizado, logrando altas tasas de éxito en pacientes estables. Los pacientes inestables o en los que se sospeche perforación de víscera hueca, requerirán cirugía como primera aproximación.

INTRODUCTION: Bicycle accidents are a frequent cause of blunt abdominal trauma in children. In Chile, there are no scientific articles about such accidents, their presentation and management. OBJECTIVE: The aim of this study is to describe three cases of blunt abdominal trauma due to handlebar injury in children, in order to illustrate the different kinds of lesions, their presentation, and management. CLINICAL CASES: 1) 11-year-old boy presented to Emergency Department (ED) after falling on a bi cycle handlebar, hitting his epigastric region. A CT scan showed signs of duodenal perforation. A la parotomy was performed and the duodenal perforation repaired. 2) 14-year-old boy seen at ED after a bicycle accident in which the handlebar hit him in the abdomen area. A CT scan showed a splenic injury with multiple lacerations and active bleeding that was treated with angioembolization. After 6 weeks of follow-up, he presented resolution of the lesion and viability of the spleen. 3) 9-year-old boy admitted due to a hit with the bicycle handlebar on the abdomen area. A CT scan showed a he patic injury that was managed with non-surgical procedures, achieving resolution of the lesion after 8 weeks of follow-up. CONCLUSION: Blunt abdominal trauma caused by handlebar can be potentially serious in pediatric patients, since it may affect solid and hollow abdominal viscera. Non-surgical ma nagement is becoming more used for stable patients, achieving high success rates. Unstable patients or those with suspicion of hollow viscera perforation will require surgery as first approach.

Perforación traumática aislada de la vesícula biliar: revisión de la literatura actual con reporte de un caso / Isolated gallbladder perforation following blunt abdominal trauma: literature review and case report

Resumen Introducción La lesión de la vesícula biliar secundaria a trauma abdominal cerrado constituye un evento infrecuente de perforación traumática de ella, de presentación tardía. Objetivo Revisar la literatura científica actualmente disponible y además describimos un caso. Materiales y Método Utilizando la plataforma PubMed se buscan las siguientes palabras clave: " Blunt abdominal trauma ". Se seleccionan las series con lesiones de la vesícula biliar: " Traumatic gallbladder rupture". Se seleccionan los reportes de lesiones aisladas de la vesícula biliar: " Isolated gallbladder rupture ". Se seleccionan los reportes de presentación tardía de lesiones aisladas de la vesícula biliar: " Delayed presentation of isolated gallbladder rupture ". Resultados De todas estas publicaciones se seleccionan las que a criterio de los autores son relevantes para el presente caso. Discusión La mayoría de las perforaciones de la vesícula biliar se producen en vesículas sanas de paredes delgadas distendidas por el ayuno o el consumo de alcohol. No existe una presentación clínica clásica. Los estudios imagenológicos son inespecíficos y se llega al diagnóstico definitivo durante la exploración quirúrgica. El tratamiento de esta lesión es la colecistectomía. Conclusiones El diagnóstico no es fácil, pero la resolución es relativamente simple y el pronóstico es bueno. El presente caso ilustra este tipo de lesiones en pacientes con trauma abdominal cerrado.

Introduction Gallbladder injury secondary to blunt abdominal trauma is a rare event. Aim Review the current available scientific literature and describe a case. Materials and Method Using the PubMed platform, the following keywords were searched: "Blunt abdominal trauma". Series with gallbladder lesions were selected: "Traumatic gallbladder rupture". Reports of isolated lesions of the gallbladder were selected: "Isolated gallbladder rupture". Reports of late presentation of isolated lesions of the gallbladder were selected: "Delayed presentation of isolated gallbladder rupture". Of all these publications, those that were relevant to the present case were selected according to the criteria of the authors. Case report A 20 years-old male patient suffered an abdominal trauma two weeks before presentation at our Institution. He underwent an exploratory laparotomy showing bilious content and a gallbladder perforation over the peritoneal wall as an isolated injury. Discussion Most isolated gallbladder perforations occur in healthy gallbladders with thin walls and distended because fasting or alcohol consumption. There are no classical clinical features to diagnose this specific injury and radiologic studies are nonspecific. Definitive diagnosis is often reached during surgery as it was with our patient. Recommended treatment is cholecystectomy. Conclusions This case illustrates this unique kind of gallbladder injury in patients with blunt abdominal trauma. A clear diagnosis is not easy however, the treatment is simple and prognosis is good.

Selective conservative treatment for anterior abdominal gunshot: a literature narrative review / Tratamento seletivo não operatório para ferimentos penetrantes por projéteis de arma de fogo na parede anterior do abdome: revisão narrativa da literatura

ABSTRACT The nonoperative treatment of anterior abdominal gunshot wounds remains controversial. This article presents a narrative review of the literature after the selection of studies in electronic databases (PubMed, Cochrane Library and Lilacs), with the intention of evaluating the clinical and diagnostic tools that should be part of conservative selective approach of these lesions. It was observed that a nonoperative selective treatment can be effectively and safely used, when performed by a trained interdisciplinary team, working in adequate trauma centers. The selective nonoperative treatment is associated with a decrease in negative and nontherapeutic laparotomies, reducing the incidence of complications. It also contributes to the reduction of hospital costs.

RESUMO O tratamento não operatório de ferimentos abdominais causados por projéteis de armas de fogo ocorridos na região anterior do abdome permanece controverso. Este artigo apresenta revisão narrativa da literatura após a seleção de estudos levantados em bancos de dados eletrônicos (PubMed, Cochrane Library e Lilacs), com a intenção de avaliar os parâmetros clínicos e exames de diagnóstico que deverão fazer parte do da abordagem conservadora seletiva dessas lesões. Avaliando os estudos selecionados, foi verificado que conduta não operatória seletiva pode ser empregada de forma eficaz e segura, quando realizada por equipe interdisciplinar treinada, atuando em Centros de Traumas adequados para a realização deste tipo de atendimento. O tratamento não operatório seletivo está associado à diminuição de laparotomias negativas e não terapêuticas, reduzindo a incidência de complicações, além de colaborar para a diminuição dos custos hospitalares.

Adopción de la laparotomía exploradora como tratamiento del trauma abdominal penetrante durante la Primera Guerra Mundial (1914-1918) / Adoption of exploratory laparotomy as a treatment of penetrating abdominal trauma during the First War World Cup (1914-1918)

La laparotomía exploradora continúa siendo el tratamiento estándar para el trauma abdominal penetrante desde la Primera Guerra Mundial (1914-1918). La conducta conservadora de finales de siglo XIX y principios del XX evolucionó a la intervencionista. Los cirujanos de los servicios sanitarios aliados de la Gran Guerra reconocieron la importancia de la intervención precoz, ejecutaron las primeras celiotomías exploradoras del hemisferio occidental de manera estandarizada y disminuyeron la mortalidad por este tipo de heridas. La retroalimentación entre la experiencia civil y militar en la terapéutica quirúrgica ha permitido la incorporación de avances en el tratamiento de este tipo de lesiones.(AU)

The exploratory laparotomy for penetrating abdominal trauma is the main treatment since the First World War. The conservative management was changed since the end of the century XIX and initial of the century XX to intervention. The allied surgeons of Great War applied the immediate surgical explorations, made the firsts celiotomies in Western Hemisphere and descended the mortality for this kind of patology. The symbiosis between the civil and military experience contribute to contemporary advances in this kind of surgeries.(AU)

Evaluación de criterios para laparotomía en lesiones abdominales por arma blanca / Laparotomy criteria assessment in abdominal stab wounds

Introducción: las lesiones traumáticas penetrantes del abdomen involucran usualmente la violación de la cavidad abdominal por una herida realizada con arma blanca u otro tipo de objeto cortopunzante. Esto constituye un problema de salud y uno de los motivos de urgencia, más comunes en la consulta de cirugía. En Cuba, los accidentes donde se incluyen este tipo de lesiones constituyeron la quinta causa de defunciones, en ambos sexos, en el año 2014. Objetivo: evaluar los criterios indicativos de laparotomía en pacientes con heridas abdominales por arma blanca. Método: se realizó un estudio de evaluación de medios diagnósticos en pacientes sometidos a una laparotomía exploratoria por herida abdominal con arma blanca. La población estuvo constituida por todos los pacientes con este tipo de lesión y la muestra por los intervenidos quirúrgicamente. Se evaluaron diversos elementos clínicos y complementarios indicativos de laparotomía ante la posibilidad de lesión orgánica significativa. Resultados: la edad promedio fue de 32 años; predominó el sexo masculino (91,3 por ciento). De los pacientes, 41,3 por ciento se presentaron signos de intoxicación exógena, y 51,25 por ciento de las laparotomías fueron terapéuticas. Mostraron mejores resultados de sensibilidad, especificidad y valores predictivos positivos la presencia de choque hipovolémico (84,2 por ciento), signos clínicos de hemorragia continua (82,4 por ciento) y perforación obvia del tracto gastrointestinal (90,9 por ciento). Entre los complementarios la laparoscopia mostró valores de sensibilidad (89,5 por ciento) y especificidad (81,8 por ciento) superior al resto. Conclusiones: el choque hipovolémico, los signos de hemorragia continua, signos de perforación obvia del tracto gastrointestinal, y la laparoscopia revelaron los mejores resultados como criterios indicativos de laparotomía en heridas abdominales por arma blanca(AU)

Introduction: penetrating traumatic lesions of the abdomen usually leads to damage in the abdominal cavity from a wound caused with a white weapon or other sharp-piercing object. This circumstance constitutes a health problem and one of the most common reasons for emergency consultation in surgery. This type of lesions was the fifth leading cause of death for both sexes in Cuba in 2014. Objective: to evaluate the criteria indicative of laparotomy in patients with abdominal wounds caused with a white weapon. Method: a diagnostic modalities assessment study was carried out in patients who underwent exploratory laparotomy for abdominal wound caused by a white weapon. The target group was made up by the patients with this type of lesions. The sample consisted of surgery patients (n= 80). Several clinical and complementary elements indicative of laparotomy were assessed before the possibility of significant organic lesions. Results: the average age was 32 years, with a predominance of males (91.3 percent). 41.3 percent of the patients showed exogenous intoxication signs, only 51.25 percent of laparotomies were therapeutic ones. The presence of hypovolemic shock (84.2 percent), clinical signs of ongoing bleeding (82.4 percent) and obvious gastrointestinal tract perforation (90.9 percent) showed better sensitivity, specificity and positive predictive values. Among the complementary tests, laparoscopy showed values of sensitivity (89.5 percent) and specificity (81.8 percent) higher than the others. Conclusions: hypovolemic shock, signs of ongoing bleeding and signs of obvious gastrointestinal tract perforation, and laparoscopy showed the best results as criteria indicative of laparotomy in abdominal stab wounds(AU)

Predictors of "occult" intra-abdominal injuries in blunt trauma patients / Indicadores de lesões intra-abdominais "ocultas" em pacientes vítimas de trauma fechado admitidas sem dor abdominal ou alterações no exame físico do abdome

Objective: to assess predictors of intra-abdominal injuries in blunt trauma patients admitted without abdominal pain or abnormalities on the abdomen physical examination. Methods: We conducted a retrospective analysis of trauma registry data, including adult blunt trauma patients admitted from 2008 to 2010 who sustained no abdominal pain or abnormalities on physical examination of the abdomen at admission and were submitted to computed tomography of the abdomen and/or exploratory laparotomy. Patients were assigned into: Group 1 (with intra-abdominal injuries) or Group 2 (without intra-abdominal injuries). Variables were compared between groups to identify those significantly associated with the presence of intra-abdominal injuries, adopting p<0.05 as significant. Subsequently, the variables with p<0.20 on bivariate analysis were selected to create a logistic regression model using the forward stepwise method. Results: A total of 268 cases met the inclusion criteria. Patients in Group I were characterized as having significantly (p<0.05) lower mean AIS score for the head segment (1.0±1.4 vs. 1.8±1.9), as well as higher mean AIS thorax score (1.6±1.7 vs. 0.9±1.5) and ISS (25.7±14.5 vs. 17,1±13,1). The rate of abdominal injuries was significantly higher in run-over pedestrians (37.3%) and in motorcyclists (36.0%) (p<0.001). The resultant logistic regression model provided 73.5% accuracy for identifying abdominal injuries. The variables included were: motorcyclist accident as trauma mechanism (p<0.001 - OR 5.51; 95%CI 2.40-12.64), presence of rib fractures (p<0.003 - OR 3.00; 95%CI 1.47-6.14), run-over pedestrian as trauma mechanism (p=0.008 - OR 2.85; 95%CI 1.13-6.22) and abnormal neurological physical exam at admission (p=0.015 - OR 0.44; 95%CI 0.22-0.85). Conclusion Intra-abdominal injuries were predominantly associated with trauma mechanism and presence of chest injuries.

Objetivo: avaliar os indicadores de lesões intra-abdominais em vítimas de trauma fechado admitidas sem dor abdominal ou alterações no exame físico do abdome. Método: estudo retrospectivo das vítimas de trauma fechado com idade superior a 13 anos, admitidas no período de 2008-2010. Selecionamos para estudo todos que foram submetidos à tomografia computadorizada de abdome e/ou laparotomia exploradora e que, à admissão, não apresentavam dor abdominal ou alterações ao exame físico do abdome. Os doentes foram separados em: Grupo 1 (com lesões intra-abdominais) e Grupo 2 (sem lesões intra-abdominais). As variáveis foram comparadas entre os grupos, considerando p<0,05 como significativo. Em um segundo passo, selecionamos as variáveis com p<0,20 na análise bivariada para criar modelo de regressão logística pelo método forward stepwise. Resultados: foram incluídos 268 casos. Os doentes com lesão abdominal caracterizaram-se por apresentar, significativamente (p<0,05), menor média de AIS em segmento cefálico (1,0 ± 1,4 vs. 1,8 ± 1,9), bem como, maior média de AIS em tórax (1,6 ± 1,7 vs. 0,9 ± 1,5) e de ISS (25,7 ± 14,5 vs. 17,1 ± 13,1). A frequência de lesões abdominais foi significativamente maior nas vítimas de atropelamentos (37,3%) e motociclistas (36%) (p<0,001). A regressão logística construiu um modelo utilizando as seguintes variáveis: motociclista como mecanismo de trauma (p<0,001- OR=5,51; IC95% 2,40-12,64), presença de fraturas de costelas (p<0,003 - OR=3,00; IC95% 1,47-6,14), atropelamento como mecanismo de trauma (p=0,008 - OR=2,85; IC95% 1,13-6,22) e exame físico neurológico anormal a admissão (p=0,015 - OR=0,44; IC95% 0,22-0,85). Conclusão: as lesões intra-abdominais foram relacionadas principalmente com o mecanismo de trauma e a presença de lesões torácicas.

El empalamiento inguinal como reto diagnóstico y terapéutico para el médico y cirujano de urgencias / Inguinal impalement; diagnostic and therapeutic challenge for emergency medical and surgeon

Introducción: el objetivo de este trabajo es presentar un caso de empalamiento a través de la región inguinal. Las heridas por empalamiento son infrecuentes y, en ocasiones, de extrema gravedad, necesitan de una actuación rápida del personal médico de urgencias y del cirujano. Caso clínico: se presenta el caso de un varón de 40 años que sufrió un accidente laboral con empalamiento de un hierro de ferralla a través de la región inguinal derecha, el cuerpo extraño penetró en la cavidad abdominal. Se expone ampliamente el caso clínico, así como los procedimientos realizados en el diagnóstico y el tratamiento de este tipo de lesiones. Conclusiones: las heridas por empalamiento son infrecuentes y suponen un reto para el personal médico que atiende al afectado desde el primer momento, tanto por lo complejas que pueden ser, como por la necesidad de una actuación rápida, sin poder conocer a priori, en muchas de las situaciones, la extensión verdadera de las lesiones, que se evidenciará durante el posible acto operatorio(AU)

Introduction: the objective of this paper was to present a case of impalement through the inguinal region. The impalement injuries are infrequent and sometimes extremely serious. These injuries require prompt action of the emergency medical personnel and surgeon. Clinical case: a forty-year old man, who had an occupational accident resulting in impalement of an iron rebar through the right inguinal region and penetrating abdominal cavity. The clinical case and the procedures performed in the diagnosis and treatment of these injuries were presented in detail. Conclusions: The impalement injuries are rare and represent a challenge to the medical staff that treat the patient from the very beginning, because they can be very complex and require fast action and treatment. In many cases, the real dimension and severity of lesions at first is unknown and can only be assessed during surgery(AU)

Identificação de lesões abdominais graves na avaliação inicial das vítimas de trauma fechado / Identifying severe abdominal injuries during the initial assessment in blunt trauma patients

OBJETIVO: avaliar os fatores preditivos de lesões abdominais graves (LAG) identificáveis na avaliação inicial das vítimas de trauma fechado. MÉTODOS: análise retrospectiva dos dados das vítimas de trauma fechado com idade superior a 13 anos submetidas à tomografia computadorizada do abdome e/ou laparotomia exploradora. Consideramos como graves as lesões com Abbreviated Injury Scale (AIS) maior ou igual a três. As variáveis foram comparadas entre os grupos A (LAG) e B (Sem LAG). Realizou-se inicialmente uma análise estatística univariada para identificar as variáveis associadas à presença de LAG. Destas, foram selecionadas para a análise multivariada (regressão logística) as que tivessem p<0,20 e pudessem ser avaliadas na admissão do doente. RESULTADOS: a amostra foi composta por 331 casos, sendo que 140 (42,3%) pacientes apresentaram lesões abdominais. Destes, 101 (30,5%) tinham lesão abdominais com AIS > 3 (Grupo A). Na análise univariada, associaram-se significativamente às LAG (p<0,05): pressão arterial sistólica (PAS) no pré-hospitalar (p=0,019), PAS à admissão (p<0,001), frequência cardíaca à admissão (p=0,047), exame físico do abdome alterado (p<0,001) e presença de fraturas de pelve (p=0,006). As seguintes variáveis se relacionaram significativamente e independentemente com a presença de lesões abdominais graves: PAS à admissão (p=0,034), exame físico abdominal alterado (p<0,001), fratura exposta de membro inferior (p<0,044), "motociclista" como mecanismo de trauma (p=0,017) e FAST positivo (p<0,001). CONCLUSÃO: das variáveis presentes na avaliação inicial, se associaram significativamente com a presença de LAG: PAS, exame físico abdominal alterado, presença de fratura exposta de membro inferior, "motociclista" como mecanismo de trauma e FAST positivo.

OBJECTIVE: To identify predictors of severe abdominal injuries using variables present in the initial assessment of blunt trauma patients. METHOD: retrospective analysis of charts and trauma data bank information including blunt trauma patients older than 13 y.o. who underwent abdominal assessment by computed tomography and/or laparotomy in a period of 18 months, starting in June 2008. Severity stratification was carried out with trauma indices (RTS, AIS, ISS and TRISS). Abdominal injuries were considered "severe" ifAIS > 3. Variables were compared between patients with SAI (group A) and without SAI (group B). Statistical analysis was carried out usingunivariate analysisinitially. We selected for logistic regression variables that would be present in the initial assessment (IA variables) and, additionally, had p<0.20 in the initial statistical analysis. RESULTS: Three hundred thirty one patients were included. Abdominal injuries were present in 140 (42.3%), being considered severe in 101 (30,5%) (Group A).Univariate analysis showed that variables significantly associated with SAI (p<0.05) in the initial analysis were: pre hospital Systolic Arterial Blood Pressure (SAP) (p=0.019), admission SAP (p<0.001), admission heart rate (p=0.047), positive abdominal physical exam on admission(p<0.001) and pelvic fractures (p=0.006). Logistic regression identified five independent factors related to SAI (IA variables): SAP (p=0.034), positive abdominal physical exam (p<0.001), open lower limbs fractures (p<0.044), motorcyclist as trauma mechanism (p=0.017) and positive FAST (p<0.001). CONCLUSION: IA variables significantly associated with SAI were SAP, positive abdominal physical examination, open lower limbs fractures, motorcyclist as mechanism of trauma and positive FAST.

Epidemiología y características clínicas, de diagnóstico y de tratamiento del trauma abdominal en el Hospital Vitarte durante el periodo 2008 a 2011 / Epidemiology and clinical features, diagnosis and treatment of abdominal trauma in Hospital Vitarte during the period 2008 to 2011

La realización del presente estudio es identificar la epidemiología y describir las características de presentación del trauma abdominal, para tener el conocimiento de base y poder proponer en un futuro estrategias de manejo y mejorar la calidad de atención hacia nuestros pacientes; ya que esta patología esta en ascenso y afecta principalmente a la población económicamente activa y el Hospital de Vitarte por su ubicación geográfica es un centro de gran importancia en la atención de estos casos.

EcoFAST: ecografía en la atención inicial del paciente traumatizado / Focused assessment with sonography for trauma (FAST)

Objetivos: Identificar mediante ecografía la presencia de líquido libre intraabdominal en pacientes politraumatizados, lo cual indica una posible lesión orgánica. Método: el ecoFAST se realiza en el área de emergencia en no más de 2 minutos, usando un transductor de 3,5 MHz, se busca la presencia de líquido en los siguientes cuatro puntos estándar con el paciente en posición supina: vista transversal de la región subxifoidea, vista longitudinal del cuadrante superior derecho, vista longitudinal del cuadrante superior izquierdo, y por último, transversal y longitudinal de la región suprapúbica. Resultados: el ecoFAST positivo significa líquido libre en uno o más de los cuatro puntos examinados, mientras que un FAST negativo significa que no hay líquido libre detectado. Conclusión: el ecoFAST proporciona al médico de emergencia un método de bajo costo, rápido, no invasivo y de fácil disponibilidad para la detección de líquido libre en el paciente politraumatizado. La técnica es fácil de aprender y posee alta sensibilidad y especifidad para la detección de líquido libre intraperitoneal.

Diagnóstico citológico de lesiones focales intra-abdominales en pacientes que acuden al Servicio de Gastroenterología del Hospital Central Universitario “Antonio María Pineda”: Barquisimeto-Estado Lara / Cytological diagnosis of intra-abdominal focal lesions in patients attending the Hospital Central Universitario

Las lesiones focales de los órganos intra - abdominales comprenden un amplio espectro, produciendo desde pocas o inaparentes consecuencias, hasta un deterioro significativo de la calidad de vida pudiendo representar una condición severa asociada con mal pronóstico y alta mortalidad. Determinar el diagnóstico citológico de lesiones focales intra-abdominales mediante punción aspiración con aguja fina en pacientes que acuden al Servicio de Gastroenterología del Hospital Central Universitario “Antonio María Pineda”. Barquisimeto. Estado Lara. Se realizó una investigación de tipo descriptiva transversal, practicándose punción aspiración con aguja fina a todos los pacientes con lesiones focales intra-abdominales que acudierón al Servicio de Gastroenterología del HCUAMP durante el periodo Julio 2008 - Diciembre 2008 excluyéndose aquellos con ausencia de un trayecto seguro para la aguja, poca abordabilidad de la lesión, trastornos de coagulación o trombocitopenia severa, infecciones de la piel en el área de la punción, enfermedades neurológicas agudas, estado crítico o terminal y pacientes poco colaboradores. 62% de los pacientes con lesiones focales intra-abdominales pertenecían al sexo femenino y 38% al sexo masculino. 54% de los pacientes tenían entre 40 y 69 años. La localización intra-abdominal más frecuente de las lesiones fue Hígado en 84%, Páncreas en 10% Retroperitoneo en 4% y Bazo en 2%. La categoría citológica fue benigna en 30% seguido de 23% maligna y 7% sospechosa para malignidad mientras que en 37% no se reportaron hallazgos citológicos patológicos. El diagnóstico citológico más frecuente de las lesiones benignas fue Absceso en 65%. De los pacientes con lesiones categorizadas como malignas, 62% presentó diagnóstico citológico de Adenocarcinoma, 15% Carcinoma, 15% neoplasia epitelial neuroendocrina y 8% Linfoma. No se presentaron complicaciones. La principal limitación fue la no disponibilidad de patólogo en el momento de la toma de las muestra...

Focal lesions in intra-abdominal organs comprehend a wide spectrum, resulting into a few or non-apparent consequences up to a significant damage of living standards, which might represent a severe condition associated with a bad patient outlook and high morbidity. Determining the cytological diagnosis of intraabdominal focal lesions by puncture/aspiration with fine needle in patients attending the Hospital Central Universitario Antonio Maria Pineda’s (HCUAMP) Gastroenterology Service, at Barquisimeto, State of Lara. A cross-sectioned descriptive research was developed; fine-needle puncture/aspiration was practiced on all patients with intra-abdominal focal lesions who attended the HCUAMP’s Gastroenterology Service between July-September 2008, excluding those who did not show a safe routing for the needle, scarce approachability to the lesion, coagulation disturbances, severe thrombocytopenia, skin infection on the puncture area, acute neurologic diseases, critical or terminal stage, and uncooperative patients. 62% of patients with intra-abdominal focal lesions were female, and 38% were male. 54% of patients were between 40 and 69 years old. The most frequent intra-abdominal lesions were: Liver, 84%; Pancreas, 10%; retroperitoneum, 4%; and Spleen, 2%. Cytological category was 30% benign, followed by 23% malignant; and 7% probably malignant, while 37% did not report pathologic cytological findings. The most frequent cytological diagnosis in benign lesions was 65% of abscess. From the patients with lesions categorized as malignant, 62% presented a cytological diagnosis of adenocarcinoma; 15%, Carcinoma; 15%, neuroendocrinal epithelial neoplasm; and 8% Lymphoma. No complications were present. The non availability of pathologist at the time of sample collection was the main limitation. The puncture/aspiration by ultrasound-guided fine needle in intraabdominal focal lesions is a rapid and efficient diagnosis alternative, rendering high specificity...

Trauma abdominal complejo en una Unidad de Cuidados Intermedios Quirúrgicos / Complex abdominal trauma in an Intermediate Surgical Care Unit

El traumatismo abdominal representa del 15-20 por ciento del total de las lesiones traumáticas. Nuestro objetivo fue conocer el comportamiento del traumatismo abdominal predominante en el lesionado complejo. Se revisaron las historias clínicas de 24 pacientes ingresados en la Unidad de Cuidados Intermedios Quirúrgicos del Hospital Militar Central Dr Luis Díaz Soto durante el año 2002, con el diagnóstico de trauma abdominal predominante. Hubo una mayor incidencia del traumatismo cerrado (70.8 por ciento), predominando en el sexo masculino (75 por ciento). El lavado peritoneal diagnóstico y la punción abdominal fueron los procedimientos más utilizados. Las lesiones más frecuentes fueron del hígado, el intestino delgado y el hematoma retroperitoneal. La hepatorrafia (30 por ciento) fue la técnica quirúrgica más empleada. Las complicaciones (29.2 por ciento) más frecuentes fueron la sepsis intraabdominal, de la herida quirúrgica y los trastornos hidroelectrolíticos. La mortalidad fue del 8.3 por ciento. La tendencia del comportamiento del traumatismo abdominal no ha logrado variarse en los últimos años, su frecuencia se mantiene estable y el tratamiento quirúrgico continúa siendo el más empleado.

The abdominal traumatism represents the 15-20 percent of the total of the traumatic lesions. Our objective was to know the behavior of the abdominal traumatism, predominant in the patients with complex lesions. We went through the clinical records of 24 patients who entered the Surgical Intermediate Care Unit of the Central Military Hospital Luis Díaz Soto during 2002, with diagnosis of predominant abdominal trauma. There was a higher incidence of the closed traumatism (70.8 percent), predominating the male sex (75 percent). The peritoneal diagnostic lavage and the abdominal punction were the most used procedures. The most frequent lesions were those in the liver, the small intestine and the retroperitoneal hematoma. Hepatorraphy (30 percent) was the most used surgical technique. The most frequent complications (29.2 percent) intra-abdominal sepsis, complications of the surgical injury and electrolytic disturbs. There was 8.3 percent of mortality. There was not any variation of the abdominal traumatism behavior tendency achieved in the last years, its frequency is steady and the surgical treatment is still the most used.

Compactação primária do abomaso em 14 bovinos no estado de Pernambuco / Primary abomasal impaction in 14 cattle from Pernambuco State, northeastern Brazil

Apesar de forragens grosseiras e secas serem empregadas comumente na alimentação de vacas em várias regiões, especialmente durante o período seco, a compactação primária do abomaso tem sido pouco relatada no Brasil, provavelmente pela dificuldade de diagnóstico dos veterinários de campo. Este trabalho objetivou realizar um estudo retrospectivo sobre a compactação primária do abomaso em 14 bovinos no Estado de Pernambuco. Oito casos considerados moderados, sem grave distensão abdominal e sem compactação do rúmen, foram tratados conservativamente e quatro casos graves, com severa distensão abdominal e compactação do rúmen, foram tratados cirurgicamente. Um touro foi encaminhado para abate e uma vaca morreu antes de receber qualquer tratamento. O maior número de casos de compactação do abomaso ocorreu em bovinos da raça Holandesa com seis casos (42,9 por cento), seguido por animais mestiços com cinco casos (35,8 por cento) e as raças Pardo-Suiça, Nelore e Marchigiana com um caso cada (21,3 por cento). A composição da alimentação oferecida caracterizou-se por conter fibra de baixa qualidade e variou bastante dentre os casos. Os sinais clínicos mais frequentes foram comportamento apático, desidratação, timpanismo ruminal associado à hipomotilidade, distensão abdominal, hipomotilidade intestinal e fezes escassas ou ausentes com presença de muco. Os achados hematológicos revelaram, na maioria dos casos, leucocitose por neutrofilia e hiperfibrinogenemia. Na análise do fluido ruminal havia comprometimento da dinâmica da flora e fauna microbiana, e elevação no teor de cloreto. O índice de recuperação clínica (4/8) e cirúrgica (2/4) observado neste estudo foi de 50 por cento. As condutas clínica e cirúrgica permanecem como opções viáveis para o tratamento das compactações leves e severas, entretanto o prognóstico é considerado reservado, principalmente quando associado à gestação avançada.

Despite the frequent use of dry and fibrous roughage for feeding cows in many regions, especially during the dry season, impaction of the abomasum has been poorly reported in Brazil, probably because the condition is misdiagnosed by practitioners. The present paper aimed to accomplish a retrospective study on primary abomasal impaction in 14 cattle from Pernambuco State, northeastern Brazil. Eight moderate cases, without severe abdominal distention and with no rumen compaction, were treated conservatively, and four severe cases, with severe abdominal distention and rumen compaction, were treated surgically. One bull was slaughtered and one cow died without treatment. The greater number of abomasal impaction cases was in Holstein cows with six cases (42.9 percent), followed by crossbred cattle with five cases (35.8 percent), and the breeds Brown-Swiss, Nelore and Marchigiana, each with one case (21.3 percent). The food composition was characterized by low quality fibers and varied greatly among cases. Most frequent clinical signs were apathy, dehydration, hypomotility and ruminal bloat, intestinal hypomotility and scanty or absent feces with mucus. The hematological findings revealed leukocytosis with neutrophilia and hyperfibrinogenemia in most cases. Ruminal fluid analysis showed compromised flora and fauna dynamics and increased chlorine ion concentration. Clinical (4/8) and chirurgical (2/4) recovery rate achieved 50 percent. The clinical and chirurgical methods remain as viable options for the treatment of light and severe impaction, but the prognosis is always reserved especially when associated to late pregnancy.

Aplicación del índice predictivo de reintervención abdominal en el diagnóstico de complicaciones infecciosas intraabdominales / Application of the predictive index of abdominal reintervention in diagnosis of intraabdominal infectious complications

Introducción: Las complicaciones infecciosas intraabdominales constituyen una condición que agrava el pronóstico de los pacientes laparotomizados y que aun en nuestros días resulta de difícil diagnóstico y tratamiento eficaz. Objetivo: Evaluar el índice predictivo de reintervención abdominal en los pacientes laparotomizados. Métodos: Se realizó un estudio observacional, prospectivo y transversal con 200 pacientes laparotomizados en el Instituto Superior de Medicina Militar Dr Luis Díaz Soto, en el periodo comprendido desde enero de 1995 hasta agosto de 1996. Los pacientes se dividieron en 2 grupos según estado al egreso y criterio de reintervención. La asociación entre variables se determinó con la prueba de X² con un 95 por ciento de confiabilidad e intervalo de confianza del 95 por ciento, y razón de productos cruzados para la medida del efecto. Se expresó la calidad diagnóstica en términos de sensibilidad, especificidad, valores predictivos positivos y negativos. Resultados: El grupo de edad mayor de 50 años fue el más reintervenido. Hubo una fuerte asociación entre los valores de índice predictivo de reintervención abdominal mayor que 11 y la reintervención (X²= 134,3194; p= 0,000). Todas las variables de índice predictivo de reintervención abdominal (excepto trastorno de la conciencia) mostraron una fuerte asociación con la decisión de reintervención. Se demostró la calidad de índice predictivo de reintervención abdominal a través de sensibilidad de 97,67 por ciento, IC [96,48-98,86], especificidad de 80,89, IC [80,54-81,25], e índice de validez de 84,50 por ciento, IC [84,22-84,78]. CONCLUSIONES: El índice predictivo de reintervención abdominal es una excelente herramienta de apoyo al cirujano para el diagnóstico de una complicación infecciosa intraabdominal, válida y fácil de implementar.

Introduction: Intraabdominal infectious complications are conditions that worsen the prognosis of patients undergoing laparotomy and even today, they are difficult to be diagnosed and efficiently treated. Objetive: To evaluate the predictive index of abdominal reintervention in laparotomized patients. Methods: A prospective, observational cross-sectional study was performed on 200 laparotomized patients at Dr Luis Díaz Soto Higher Institute of Military Medicine from January 1995 to August 1996. The patients were divided into two groups according to their health status at discharge and the criteria for reintervention. The variable association was determined by X² test with 95 percent CI, and cross product ratio for effect measurement. The diagnostic quality was based on sensitivity, specificity and positive and negative predictive values. Results: The highest number of reinterventions was found in the over 50 years-old age group. There was close association between abdominal reintervention predictive index scores higher than 11 and reintervention (X²= 134.3194; p= 0.000). All abdominal reintervention predictive index variables (except for altered consciousness) were highly associated with the decision to perform reintervention. The quality of abdominal reintervention predictive index was proved since sensitivity was 97.67 percent, CI [96.48-98,98.86], specificity was 80.89, CI [80.54-81.25] and validity index reached 84.50 percent, CI [84.22-84.78]. Conclusions: The abdominal reintervention predictive index is an excellent, valid and easy to use tool for the surgeon in diagnosing intraabdominal infectious complication.

Lesiones de vejiga por trauma abdominal en el Hospital Central de la Cruz Roja Mexicana / Bladder injuries due to abdominal trauma in patients treated at the Central Hospital of the Mexican Red Cross

Introducción: El 10 % de las lesiones traumáticas abdominales involucra la vía urinaria, de éstas 25 % corresponde a trauma vesical. El tipo de lesión depende del mecanismo de acción contuso o penetrante. Los síntomas incluyen hipersensibilidad hipogástrica e imposibilidad para la micción; el signo más importante es la hematuria. Material y métodos: Se realizó estudio retrospectivo observacional y descriptivo de los pacientes con lesión vesical atendidos de enero de 2001 a septiembre de 2007 en el Hospital Central de la Cruz Roja Mexicana de la Ciudad de México; fueron excluidos aquellos con lesiones iatrogénicas. Resultados: Se encontraron 46 casos de lesión vesical, 35 hombres (76 %) y 11 mujeres (24 %). La edad promedio fue de 29 años. El mecanismo de la lesión fue contusión cerrada en 63 % y por herida penetrante en 37 %. El diagnóstico se estableció en 26 % por cistograma retrógrado y en 74 % por laparotomía exploradora, en la cual se identificó lesión asociada de más de dos órganos. El tratamiento dependió de la condición de intra o extraperitoneal; no se informaron complicaciones. Conclusiones: Los pacientes con lesión vesical por trauma son más jóvenes en relación a los que padecen daño iatrogénico y con predominio del sexo masculino. El traumatismo cerrado de abdomen impera sobre el penetrante. La hematuria macroscópica es el síntoma más constante. La lesión vesical asociada a fractura pélvica tuvo baja incidencia. La laparotomía exploradora fue el principal método diagnóstico debido a que lesiones asociadas indicaban la realización inmediata del procedimiento.

BACKGROUND: Abdominal traumas involving the urinary tract represent 10% and, of these, 25% are for bladder trauma. Type of injury depends on the mechanism of action, whether blunt or penetrating. Symptoms include hypogastric hypersensitivity and inability to urinate. The most important sign is hematuria. METHODS: This was a retrospective, observational study and descriptive analysis of patients with bladder injury, excluding iatrogenic injury. RESULTS: There were 46 cases of bladder injury comprising 35 men (76%) and 11 women (24%). Mean age was 29 years. Mechanism of injury was closed contusion (63%) and penetrating wound (37%). Diagnosis was established in 74% of cases by exploratory laparotomy and in 26% of cases by cystography. Treatment was in accordance with intra- or extraperitoneal status, and there were no reported complications. CONCLUSIONS: Patients with traumatic injuries are often young and male, in relation to patients with iatrogenic damage. Closed abdominal trauma is prevalent with penetration. Gross hematuria is the most consistent symptom. Incidence of bladder injury associated with pelvic fracture was low. Exploratory laparotomy was the primary diagnostic method, with cystography done in a limited number of patients. There were no complications.

[ role of thoracoscopy in diagnosis of hidden diaphragmatic injuries in penetrating thoracoabdominal traumas]

Complications like chronic diaphragmatic hernia thoracoabdominal stab wound following conservative treatment, make it necessary to find a safe and exact diagnostic method. The aim of this work was to assess, accurate diagnostic value of thoracoscopy in occult diaphragmatic injuries in penetrating thoracoabdominal stab wound. In the present prospective study, from March 2005 to October 2007 at Ghaem, Emam Reza and Shahid Kamyab Hospitals of Mashhad University of Medical Sciences, thirty patients with penetrating thoracoabdominal injuries, with stable hemodynamic and no need to emergent exploration were evaluated. They underwent thoracoscopy to evaluate probable diaphragmatic injuries, which were repaired via thoracoscopy or laparatomy and all patients evaluated for chronic diaphragmatic hernia by CT-scan, 6 months later. Mean age was 26.2 years and M/F ratio was 5:1. In thoracoscopic evaluations five hidden diaphragmatic injuries [16.7%] were observed, that 3 cases [9.9%] were repaired through thoracoscopic approach and laparatomy was inevitable in 2 [6.6%] patients. Lung paranchymal laceration was seen in 2 patients [6.6%], repaired with thoracoscopy and intra abdominal injury was seen in 1 patient [3.3%], repaired with loparatomy. No complication reported after thoracoscopy and there was no evidence of chronic diaphragmatic hernia in the chest and abdominal CT-scan performed 6 months later. In this study, the diagnostic accuracy of thoracoscopy in occult diaphragmatic injuries was 100%. Because of high diagnostic accuracy rate, and minimal invasively diagnostic and treatment ability of thoracoscopy, this diagnostic method in all clinically stable patients with penetrating thoracoabdominal stab wound is recommended

Endoscopic cystogastrostomy.

Endoscopic cystoenterostomy for drainage of pancreatic pseudocyst is a new emerging modality which has rarely been reported in pediatric patients. Only ten successfully performed cases of pediatric endoscopic cystoenterostomy have been reported previously. We report a case of 9 year old male child with post traumatic pseudocyst of pancreas, successfully managed by endoscopic cystogastrostomy. To best of our knowledge, this is the first pediatric case report in Indian literature.