Non-operative management of blunt splenic trauma: evolution, results and controversies / Tratamento não operatório do trauma esplênico: evolução, resultados e controvérsias

ABSTRACT The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

RESUMO O baço é um dos órgãos mais frequentemente afetados no trauma abdominal contuso. Desde os trabalhos de Upadhyaya, o tratamento do trauma esplênico vem sofrendo importantes modificações. Atualmente, é consenso que todo trauma esplênico que se apresenta com estabilidade hemodinâmica pode ser tratado inicialmente de forma não operatória, desde que o serviço possua estrutura adequada e o paciente não apresente outras condições que indiquem exploração da cavidade abdominal. Entretanto, vários tópicos permanecem controversos no que diz respeito ao tratamento não operatório (TNO) do trauma esplênico. A angioembolização esplênica é uma ferramenta de grande auxílio no TNO, porém não há consenso sobre suas indicações precisas. Não há uma definição na literatura a respeito da forma como o TNO deve ser conduzido, tampouco a respeito da periodicidade do controle hematimétrico, do limiar de transfusão que define falha do TNO, de quando iniciar a profilaxia contra tromboembolismo venoso, da necessidade de exames de imagem de controle, do período de repouso no leito, e de quando é seguro indicar alta hospitalar. O objetivo desta revisão é analisar de forma crítica a literatura a respeito desse tema, expondo o estado da arte no TNO do trauma esplênico.

Ruptura diafragmática y esplénica de origen traumático en un adolescente / Diaphragmatic and splenic rupture of traumatic origin in a teenager

Introducción: La ruptura diafragmática es un reto diagnóstico y terapéutico para los médicos que se enfrentan al manejo de pacientes politraumatizados; debe sospecharse siempre en lesiones traumáticas de localización torácica o abdominal. Objetivo: Informar los elementos diagnósticos y terapéuticos seguidos ante ruptura diafragmática y esplénica de origen traumático. Presentación del caso: Se presenta el caso de un adolescente de 14 años que ingresa por presentar herida punzante por arma blanca de localización abdominal y manifestaciones clínicas que permiten hacer el diagnóstico de la afección tratada. Durante el acto quirúrgico se comprobó la ruptura del diafragma, hernia diafragmática y ruptura esplénica con salida de sangre hacia la cavidad abdominal. Se realizó reducción de la hernia, sutura del diafragma y extirpación del bazo por el estado del órgano en el momento de la cirugía. Conclusiones: La ruptura diafragmática postraumática es una entidad que cada vez se observa con mayor frecuencia en pacientes pediátricos. El examen clínico auxiliado por estudios imagenológicos resulta vital para su diagnóstico, tratamiento precoz y evitar complicaciones. Es importante mantener un alto índice de sospecha ante esta entidad poco frecuente, pero no rara en la edad pediátrica. El paciente tuvo una evolución favorable y fue egresado del servicio de cirugía luego de 10 días de hospitalización(AU)

Introduction: The diaphragmatic rupture is a diagnostic and a therapeutic challenge for physicians who have to face the management of polytraumatized patients; there must always be suspicion on traumatic injuries of thoracic or abdominal location. Objective: To inform the diagnostic and therapeutic elements followed in case of diaphragmatic and splenic rupture of traumatic origin. Presentation of the case: 14-year-old male teenager that was admitted for presenting stabbing wound by sharp weapon, with abdominal location and clinical manifestations that allow making the diagnosis of the condition being treated. During surgery, it was found the rupture of the diaphragm, a diaphragmatic hernia and splenic rupture with output of blood into the abdominal cavity. It was conducted the reduction of the hernia, the suture of the diaphragm and the removal of the spleen due to the state of the organ during the surgery. Conclusions: Post-traumatic diaphragmatic rupture is an entity that it is most often seen in pediatric patients. The clinical examination aided by imaging studies is vital for its diagnosis, early treatment and to avoid complications. It is important to maintain a high index of suspicion to face this rare entity, but not so rare in the pediatric age group. The patient had a favourable evolution and he was discharged of the surgery service after 10 days of hospitalization(AU)

Mesenteric lymph drainage alleviates hemorrhagic shock-induced spleen injury and inflammation

Abstract Purpose: To investigate the effect of mesenteric lymph drainage on the spleen injury and the expressions of inflammatory cytokines in splenic tissue in mice following hemorrhagic shock. Methods: Male C57 mice were randomly divided into the sham shock, shock and shock+drainage groups. The mice in both shock and shock+drainage groups suffered femoral artery bleeding, maintained mean arterial pressure (MAP) of 40±2 mmHg for 90 min, and were resuscitated. And mesenteric lymph drainage was performed in the shock+drainage group at the time of resuscitation. After three hours of resuscitation, the splenic tissues were harvested for the histological observation and protein and mRNA expression analysis of cytokines. Results: The spleen in the shock group revealed a significantly structural damage and increased mRNA expressions of MyD88 and TRAF6 and protein expressions of TIPE2, MyD88, TRIF and TRAF3 compared to the sham group. By contrast, the splenic pathological injury in the shock+drainage group was alleviated significantly, and the mRNA and protein expressions of TIPE2, MyD88, TRIF, TRAF3 and TRAF6 were significantly lower than those in the shock group. Conclusion: These results indicate that post-hemorrhagic shock mesenteric lymph drainage alleviates hemorrhagic shock-induced spleen injury and the expressions of inflammatory cytokines.

Should splenic autotransplantation be considered after total splenectomy due to trauma? / Autoimplante esplênico deve ser considerado para pacientes submetidos à esplenectomia total por trauma?

ABSTRACT Trauma is a public health problem and the most common cause of death in people under the age of 45. In blunt abdominal trauma, the spleen is the most commonly injured organ. Splenectomy remains the most common treatment, especially in high-grade lesions, despite increased nonoperative treatment. Removal of the spleen leads to increased susceptibility to infections due to its role in the immune function. Postsplenectomy sepsis is an important complication and presents a high mortality rate. Patients undergoing splenectomy should be immunized for encapsulated germs, as these are the agents most commonly associated with such infections. Splenic autotransplantation is a simple procedure, which can be an alternative to reduce infection rates consequent to total splenectomy, and reduce costs related to hospitalizations. This review aims to provide evidence-based information on splenic autotransplantation and its impact on the prognosis of patients undergoing total splenectomy. We searched the Cochrane Library, Medline/PubMed, SciELO and Embase, from January 2017 to January 2018 and selected articles in English and Portuguese, dated from 1919 to 2017. We found that the adjusted risk of death in splenectomized patients is greater than that of the general population, and when total splenectomy is performed, splenic autotransplantation is the only method capable of preserving splenic function, avoiding infections, especially postsplenectomy sepsis. Health professionals should be familiar with the consequences of the method chosen to manage the patient suffering from splenic trauma.

RESUMO O trauma é um problema de saúde pública e a causa mais comum de óbito em pessoas com menos de 45 anos de idade. Nos traumas abdominais contusos, o baço é o órgão mais comumente lesado. A esplenectomia continua sendo o tratamento mais comum, especialmente em lesões de alto grau, apesar do aumento do tratamento não operatório. A remoção do baço gera aumento da suscetibilidade a infecções, devido ao seu papel na função imune. Sepse pós-esplenectomia é uma importante complicação e apresenta alta taxa de mortalidade. Pacientes submetidos à esplenectomia devem receber imunização para germes encapsulados, por serem os agentes mais comumente relacionados a essas infecções. Autoimplante esplênico é um procedimento simples, que pode ser alternativa para reduzir índices de infecção consequentes à esplenectomia total, e que pode reduzir custos relacionados à internações. Este trabalho de revisão objetiva prover informações baseadas em evidências sobre o autoimplante esplênico e seu impacto no prognóstico de pacientes submetidos à esplenectomia total. Foram realizadas buscas na Cochrane Library, Medline/PubMed, SciELO e Embase, de janeiro de 2017 a janeiro de 2018 e selecionados artigos em inglês e português, datados de 1919 a 2017. Verificou-se que o risco ajustado de morte em pacientes esplenectomizados é maior do que o da população geral, e quando a esplenectomia total é realizada, o autoimplante esplênico é o único método capaz de preservar a função esplênica, evitando infecções, principalmente sepse pós-esplenectomia. Profissionais de saúde devem estar familiarizados com as consequências do método escolhido para manejar o paciente vítima de trauma esplênico.

Factores asociados a falla en el manejo no operatorio de lesiones hepáticas o esplénicas secundarias a trauma abdominal cerrado en niños / Associated factors to non-operative management failure of hepatic and splenic lesions secondary to blunt abdominal trauma in children

Introducción: El manejo no operatorio (MNO) es el manejo estándar del trauma cerrado esplénico y hepático en el paciente pediátrico. Se han identificado como fallas a este manejo inestabilidad hemodinámica y transfusiones masivas. Pocos trabajos evalúan si existen factores que permitan una anticipación a estos eventos. El objetivo fue determinar la existencia de factores asociados a la falla en MNO de las lesiones esplénicas y/o hepáticas secundarias al trauma abdominal cerrado. Pacientes y Método: Análisis retrospectivo 2007 a 2015 de los pacientes que ingresaron al servicio de Cirugía infantil del Hospital Universitario San Vicente Fundación con trauma hepático y/o esplénico cerrado. Resultados: Ingresaron 70 pacientes con trauma cerrado de abdomen, 3 fueron excluidos por cirugía inmediata (2 inestabilidad hemodinámica y 1 irritación peritoneal). De 67 pacientes que recibieron MNO, 58 tuvieron éxito y 9 presentaron falla (8 inestabilidad hemodinámica y 1 lesión de víscera hueca). Encontramos 3 factores asociados a la falla MNO: presión arterial (PAS) < 90 mmHg al ingreso (p=0,0126; RR =5,19), caída de la Hemoglobina (Hb) > 2 g/dl en las primeras 24 h (p=0,0009; RR= 15,3), y transfusión de 3 o más unidades de glóbulos rojos (UGR) (0,00001; RR= 17,1). Mecanismo del trauma, severidad e Índice de Trauma Pediátrico no se asociaron con fallo MNO. Conclusiones: Los niños con trauma cerrado hepático o esplénico responden al MNO. Los factores como PA menor de 90 al ingreso, caída de la Hb >2 g/dl en las primeras 24 h y la transfusión de 3 o más UGR pueden asociarse con la falla en el MNO.

Introduction: The non operative management (NOM) is the standard management of splenic and liver blunt trauma in pediatric patients.Hemodynamic instability and massive transfusions have been identified as management failures. Few studies evaluate whether there exist factors allowing anticipation of these events. The objective was to identify factors associated with the failure of NOM in splenic and liver injuries for blunt abdominal trauma. Patients and Method: Retrospective analysis between 2007-2015 of patients admitted to the pediatric surgery at University Hospital Saint Vincent Foundation with liver trauma and/or closed Spleen. Results: 70 patients were admitted with blunt abdominal trauma, 3 were excluded for immediate surgery (2 hemodynamic instability, 1 peritoneal irritation). Of 67 patients who received NOM, 58 were successful and 9 showed failure (8 hemodynamic instability, 1 hollow viscera injury). We found 3 factors associated with failure NOM: blood pressure (BP) < 90 mmHg at admission (p = 0.0126; RR = 5.19), drop in hemoglobin (Hb) > 2 g/dl in the first 24 hours (p = 0.0009; RR = 15.3), and transfusion of 3 or more units of red blood cells (RBC) (0.00001; RR = 17.1). Mechanism and severity of trauma and Pediatric Trauma Index were not associated with failure NOM. Conclusions: Children with blunted hepatic or splenic trauma respond to NOM. Factors such as BP < 90 mmHg at admission, an Hb fall > 2 g/dl in the first 24 hours and transfusion of 3 or more units of RBC were associated with the failure in NOM.

Incidental splenic injury and splenectomy: an overview based on available evidence / Lesión esplénica incidental y esplenectomía: una visión general basada en la evidencia disponible

Splenectomy indications are hematologic disease, traumatic damage and iatrogenic injury. The aim of this study was to present an evidence-based overview of some clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy. An overview of the available evidence was conducted. Articles that evaluated clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy, without language limits, publication date and designs. BVS, PubMed, SciELO and TRIP databases were reviewed. Evaluated variables were: Frequency and etiology of surgical spleen injuries, treatment options, frequency of splenectomy, associated postoperative morbidity (POM) and mortality, recommendation for splenectomy. Classification of the available evidence was made using the classification proposed by Oxford Centre of Evidence-based Medicine. 1144 records were obtained. 1109 were discarded for not meeting eligibility criteria, or were not relevant for the purpose of this research. Finally, the study consisted of 35 articles, 3 of evidence level type 3a, 31 of evidence level type 4 and 1 of evidence level type 5. Splenectomy is a complication of common abdominal procedures, prevalence and incidence of iatrogenic splenic injury is underestimated because of lack of information, there is evidence of risk factors of surgical spleen injuries, the etiology of surgical spleen injuries are bariatric, esophago-gastric, antireflux, colorectal, abdominal vascular and urological procedures. POM in patients undergoing splenectomy is more frequent in emergency splenectomy secondary to trauma. There was no significant risk reduction of infectious complications after implementation of routine vaccination. Available evidence is based on few and heterogeneous articles, which make a meaningful conclusions difficult. Studies with better evidence levels, methodological quality and population size are needed for conclusions and recommendations.

Las indicaciones de esplenectomía son enfermedades hematológicas, daño por trauma y por lesiones iatrogénicas. El objetivo de este estudio es presentar una visión general basada en la evidencia actualmente disponible, respecto de algunos aspectos clínicos de interés relacionados con la lesión esplénica iatrogénica y posterior esplenectomía. Revisión global de la evidencia disponible. Se incluyeron artículos que evaluaron aspectos clínicos de interés relacionados con lesión esplénica iatrogénica y posterior esplenectomía; sin límites de lenguaje, fecha de publicación y diseño. Se revisaron las bases de datos BVS, PubMed, SciELO y Trip Database. Las variables evaluadas fueron: frecuencia y etiología de las lesiones, opciones de tratamiento, frecuencia de esplenectomía, morbimortalidad postoperatoria, recomendación de esplenectomía. La clasificación de la evidencia se realizó con la propuesta del Centro de Medicina Basada en la Evidencia de Oxford. Se obtuvieron 1144 registros. 1109 fueron descartados por no cumplir criterios de elegibilidad, o ser no relevantes para el objetivo de la investigación. La población en estudio quedó compuesta por 35 artículos, 3 de nivel de evidencia 3a, 31 de nivel de evidencia 4 y 1 de nivel de evidencia 5. La esplenectomía es una complicación propia de la cirugía abdominal. La prevalencia e incidencia de lesión esplénica iatrogénica es subestimada por falta de información. Hay evidencia de factores de riesgo de lesiones del bazo. La etiología de estas es: procedimientos bariátricos, esófago-gástricos, colorrectales, vasculares abdominales y urológicos. La morbilidad es más frecuente en esplenectomía de emergencia secundaria a trauma. No se ha registrado disminución significativa del riesgo de complicaciones infecciosas con la vacunación rutinaria. La evidencia disponible se basa en pocos artículos y heterogéneos, lo que impide sacar conclusiones. Se necesitan estudios de mejor nivel de evidencia, calidad metodológica y tamaño de muestra para obtener conclusiones válidas y recomendaciones adecuadas.

Main controversies in the nonoperative management of blunt splenic injuries / Principais controvérsias do tratamento não operatório das lesões contusas do baço

Introduction: The nonoperative management of traumatic spleen injuries is the modality of choice in patients with blunt abdominal trauma and hemodynamic stability. However, there are still questions about the treatment indication in some groups of patients, as well as its follow-up. Aim : Update knowledge about the spleen injury. Method: Was performed review of the literature on the nonoperative management of blunt injuries of the spleen in databases: Cochrane Library, Medline and SciELO. Were evaluated articles in English and Portuguese, between 1955 and 2014, using the headings "splenic injury, nonoperative management and blunt abdominal trauma". Results: Were selected 35 articles. Most of them were recommendation grade B and C. Conclusion: The spleen traumatic injuries are frequent and its nonoperative management is a worldwide trend. The available literature does not explain all aspects on treatment. The authors developed a systematization of care based on the best available scientific evidence to better treat this condition.

Introdução: O tratamento não operatório das lesões traumáticas do baço é a modalidade de escolha nos pacientes com trauma abdominal contuso e estabilidade hemodinâmica. No entanto, ainda existem dúvidas sobre a indicação do tratamento em determinado grupo de pacientes, assim como o seu seguimento. Objetivo : Atualizar o conhecimento sobre as lesões do baço. Método: Realizou-se revisão da literatura sobre o tratamento não operatório das lesões contusas do baço nas bases de dados: Cochrane, Medline e SciELO. Foram incluídos os artigos em línguas portuguesa e inglesa entre 1955 e 2014, utilizando os descritores "splenic injury, nonoperative management e blunt abdominal trauma". Resultado: Foram selecionados 35 artigos. A maioria dos trabalhos eran em grau de recomendação B e C. Conclusão: As lesões traumáticas do baço são frequentes e o seu tratamento não operatório apresenta tendência mundial. A literatura disponível não esclarece todos os aspectos deste tratamento. Elaborou-se sistematização de atendimento baseada nas melhores evidências científicas disponíveis para facilitar seu manejo.

Contribuição para o desenvolvimento de uma vacina contra leishmaniose visceral canina / Contribution to the development of a vaccine against canine visceral leishmaniasis

A Leishmaniose visceral (LV) é uma doença infecciosa e parasitária que se encontra em expansão no Brasil. A espécie que causa a doença no Brasil é a Leishmania infantum. O cão é o principal reservatório do parasita. Uma vacina contra leishmaniose visceral canina (LVC) pode favorecer o controle da doença. Este trabalho tem como objetivo contribuir para o desenvolvimento de uma vacina contra LVC.OBJETIVO: O estudo do primeiro capítulo visou o desenvolvimento de um modelo para a avaliação de antígenos candidatos à vacina contra LVC. METODOLOGIA: Um experimento foi realizado para obtenção de cães resistentes a LVC. Os linfócitos dos animais deveriam ser capazes de reconhecer antígenos otencialmente úteis para o desenvolvimento de uma vacina. Para isso, uma cepa de L.infantum foi isolada de cão naturalmente infectado e doente (Camaçari, Bahia). Seis cães adultos e sadios foram inoculados com 1x108 formas promastigotas em fase estacionária de cultura por via dérmica e acompanhados por dois anos.RESULTADOS: Os animais apresentaram: 1) área de induração e ulceração rasa no local da inoculação do parasita com cura espontânea em um período inferior a três meses, 2) ausência de manifestações clínicas e de alterações hematológicas e bioquímicas séricas, 3) produção baixa e flutuante de anticorpos da classe IgG reativos a antígenos de Leishmania, 4) resposta linfoproliferativa (em 4 de 6 cães) frente a estimulação com antígenos de Leishmania, 5)produção baixa de IFN-γ em um ensaio realizado com sangue total incubado por 24h com antígenos de Leishmania (4 de 5 cães), 6) carga parasitária baixa em aspirado de baço,detectada por PCR em tempo real. CONCLUSÃO: Os animais desenvolveram uma forma subclínica da infecção ao lado de resposta imune humoral e celular fracas.OBJETIVO: No segundo capítulo foi testado um ensaio de avaliação da produção de citocinas por células de sangue de cães naturalmente infectados por Leishmania infantum. O quantiFERON modificado permite a avaliação in vitro e de maneira rápida da produção de citocinas contra Leishmania em animais de área endêmica. METODOLOGIA: Antígeno solúvel e antígenos recombinantes de L. infantum (rLci2-NT-5R-CT e rLci2-NT-CT) foram produzidos e utilizados no ensaio para a estimulação do sangue total de27 cães de área endêmica e não endêmica para LVC por 24h. O plasma foi coletado e a produção das citocinas caninas IFN-γ, IL-2, IL-6, IL-10 e TNF-α foram quantificadas. RESULTADO:Devido a problemas técnicos não foi possível avaliar os dados obtidos e,consequentemente,não foi possível caracterizar grupos de animais susceptíveis e resistentes.OBJETIVO: No terceiro capítulo, a carga parasitária e aspectos histológicos em diferentes regiões do baço de cães com LVC foi analisada.METODOLOGIA: A carga parasitária e alterações histológicas no baço de 6 cães com LVC foram avaliados por amostragem de três secções inferior, média e superior do órgão...

INTRODUCTION: Visceral Leishmaniasis (VL) is an infectious parasitic disease which is increasing in Brazil. The species that causes the disease in Brazil is Leishmaniainfantum. The dog is the main reservoir of the parasite. A canine visceral leishmaniasis vaccine (CVL) may favor the control of the disease. This paper aims to contribute to the development of a vaccine against CVL. OBJECTIVE: The first chapter study aimed the development of a model for the evaluation of candidate antigens for a vaccine against CVL. An experiment was conducted to obtain resistant dogs to CVL. Lymphocytes of these animals should be able to recognize potentially useful antigens for a vaccine development. METHODOLOGY: For this, a strain of L. infantum was isolated from naturally infected and sick dog (Camaçari, Bahia). Six dogs and healthy adults were intradermally inoculated with 1 x 108 promastigotes in the stationary phase culture and were followed for two years. RESULTS: The animals showed: 1) induration area and shallow ulceration in parasite inoculation site with spontaneous healing in a period of less than three months, 2) absence of clinical symptoms and hematological and biochemical changes, 3) low and floating production of antibodies IgG reactive to Leishmania antigens, 4) lymphoproliferative response (in 4 of 6 dogs) compared to stimulation with leishmanial antigens, 5) low IFN-γ in a test performed on whole blood incubated for 24 h with antigen Leishmania (4 of 5 dogs), 6) a low parasite load in spleen aspirates, detected by realtime PCR. CONCLUSION: These animals developed a subclinical form of the infection alongside with a weakspecific humoral and cellular immune response and weak cell. OBJECTIVE: The second section was tested in a trial evaluating cytokine production by blood cells of dogs naturally infected with Leishmaniainfantum. The modified QuantiFERON allows evaluation both in vitro and quickly production of cytokines against Leishmania in animals in an endemic area. METHODOLOGY: Soluble antigen and recombinant antigens of L. infantum (rLci2-5R-NT-CT and rLci2-NT-CT) were produced and used in the assay for the stimulation of whole blood of 27 animals from endemic and nonendemic area for LVC for 24h. Plasma was collected and cytokine production of canine IFNγ, IL-2, IL-6, IL-10 and TNF-α cytokines were quantified. RESULTS: Due to technical some problems, it was not possible to characterize groups of animals susceptible and resistant in relation to modified QuantiFERON assay results. OBJECTIVE: In the third chapter, the parasite load and histological aspects in different regions of the spleen of dogs with CVL were analyzed. METHODOLOGY: The parasite load and histological changes in the spleen of 6 dogs with CVL were evaluated by sampling three sections of the spleen (lower, middle and upper section of the organ)...

Mesenteric lymph reperfusion exacerbates spleen injury caused by superior mesenteric artery occlusion shock

The intestinal lymph pathway plays an important role in the pathogenesis of organ injury following superior mesenteric artery occlusion (SMAO) shock. We hypothesized that mesenteric lymph reperfusion (MLR) is a major cause of spleen injury after SMAO shock. To test this hypothesis, SMAO shock was induced in Wistar rats by clamping the superior mesenteric artery (SMA) for 1 h, followed by reperfusion for 2 h. Similarly, MLR was performed by clamping the mesenteric lymph duct (MLD) for 1 h, followed by reperfusion for 2 h. In the MLR+SMAO group rats, both the SMA and MLD were clamped and then released for reperfusion for 2 h. SMAO shock alone elicited: 1) splenic structure injury, 2) increased levels of malondialdehyde, nitric oxide (NO), intercellular adhesion molecule-1, endotoxin, lipopolysaccharide receptor (CD14), lipopolysaccharide-binding protein, and tumor necrosis factor-α, 3) enhanced activities of NO synthase and myeloperoxidase, and 4) decreased activities of superoxide dismutase and ATPase. MLR following SMAO shock further aggravated these deleterious effects. We conclude that MLR exacerbates spleen injury caused by SMAO shock, which itself is associated with oxidative stress, excessive release of NO, recruitment of polymorphonuclear neutrophils, endotoxin translocation, and enhanced inflammatory responses.

Tratamento não operatório de lesão esplênica grau IV é seguro usando-se rígido protocolo / Nonoperative management of splenic injury grade IV is safe using rigid protocol

OBJETIVO: demonstrar o protocolo e a experiência do serviço no TNO de lesões esplênicas contusas grau IV (classificação da Associação Americana de Cirurgia do Trauma). MÉTODOS: estudo retrospectivo baseado em registro de trauma de hospital universitário no período de 1990 a 2010. Prontuários de todos os pacientes com lesão esplênica foram revisados e os doentes tratados de modo não operatório com lesão grau IV foram incluídos no estudo. RESULTADOS: noventa e quatro pacientes com lesão esplênica contusa grau IV foram admitidos neste período. Vinte e seis (27,6%) apresentaram os critérios para o TNO. A média de pressão arterial sistólica na admissão foi de 113,07 ± 22,22mmHg, RTS = 7,66 ± 0,49 e ISS = 18,34 ± 3,90. Dez pacientes (38,5%) necessitaram de transfusão sanguínea, com uma média de 1,92 ± 1,77 concentrado de hemácias por paciente. Lesões abdominais associadas estavam presentes em dois pacientes (7,7%). O TNO falhou em dois pacientes (7,7%), operados devido à piora da dor abdominal e choque hipovolêmico. Nenhum paciente desenvolveu complicações relativas ao baço e não houve óbito na presente casuística. A média de dias de internação foi 7,12 ± 1,98 dias. CONCLUSÃO: o tratamento não operatório de lesões esplênicas grau IV no trauma abdominal contuso é seguro seguindo-se rígido protocolo.

OBJECTIVE: To demonstrate the protocol and experience of our service in the nonoperative management (NOM) of grade IV blunt splenic injuries. METHODS: This is a retrospective study based on trauma registry of a university hospital between 1990-2010. Charts of all patients with splenic injury were reviewed and patients with grade IV lesions treated nonoperatively were included in the study. RESULTS: ninety-four patients with grade IV blunt splenic injury were admitted during this period. Twenty-six (27.6%) met the inclusion criteria for NOM. The average systolic blood pressure on admission was 113.07 ± 22.22 mmHg, RTS 7.66 ± 0.49 and ISS 18.34 ± 3.90. Ten patients (38.5%) required blood transfusion, with a mean of 1.92 ± 1.77 packed red cells per patient. Associated abdominal injuries were present in two patients (7.7%). NOM failed in two patients (7.7%), operated on due to worsening of abdominal pain and hypovolemic shock. No patient developed complications related to the spleen and there were no deaths in this series. Average length of hospital stay was 7.12 ± 1.98 days. CONCLUSION: Nonoperative treatment of grade IV splenic injuries in blunt abdominal trauma is safe when a rigid protocol is followed.

Tratamento não operatório do trauma de baço grave / Selective nonoperative management of high grade splenic trauma

A reunião de revista "Telemedicina baseada em evidências - Cirurgia do Trauma e Emergência" (TBE-CiTE) realizou uma revisão crítica da literatura e selecionou três artigos atuais sobre o tratamento do trauma de baço. O foco foi em lesão de baço grave, definida pela American Association for the Surgery of Trauma (AAST) como graus III a V. O primeiro artigo foi uma atualização do protocolo de 2003 da Eastern Association for the Surgery of Trauma (EAST) para o tratamento não operatório de trauma do baço. O segundo artigo foi apresentado na plenária de 2012 da AAST avaliando o papel do extravasamento de contraste na tomografia computadorizada em pacientes com lesão grave de baço (AAST IV-V). O último artigo é europeu e investigou o efeito da angioembolização da artéria esplênica na função do baço após lesão esplênica grave (AAST III-V). A reunião de revista TBE-CiTE elaborou conclusões e recomendações para o tratamento de lesão grave do baço.

The "Evidence-based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical review of the literature and selected three up-to-date articles on the management of splenic trauma. Our focus was on high-grade splenic injuries, defined as AAST injury grade III-V. The first paper was an update of the 2003 Eastern Association for the Surgery of Trauma (EAST) practice management guidelines for nonoperative management of injury to the spleen. The second paper was an American Association for the Surgery of Trauma (AAST) 2012 plenary paper evaluating the predictive role of contrast blush on CT scan in AAST grade IV and V splenic injuries. Our last article was from Europe and investigates the effects of angioembolization of splenic artery on splenic function after high-grade splenic trauma (AAST grade III-V). The EBT-TACS Journal Club elaborated conclusions and recommendations for the management of high-grade splenic trauma.

Trauma esplénico: morbilidad en pacientes en el Hospital Daniel Alcides Carrión entre los años 2002 - 2011 / Splenic trauma: morbidity in patients at the Hospital Daniel Alcides Carrion between the years 2002-2011

OBJETIVOS: Describir la morbilidad del trauma esplénico en los pacientes del hospital Daniel Alcides Carrión entre los años 2002 a 2011. MATERIAL Y METODOS: Estudio de diseño retrospectivo, observacional, transversal y descriptivo, en 129 historias clínicas con diagnóstico de trauma esplénico que fueron tratados quirúrgicamente o mediante tratamiento no operatorio, post criterios de inclusión/exclusión, siendo el instrumento principal una ficha de datos. RESULTADOS: El mayor número de pacientes se encuentra entre los 21 a 30 años de edad (27.9 por ciento). Predominio del sexo masculino (81.40 por ciento). Los mecanismos de la lesión: trauma cerrado (58.15 por ciento), trauma abierto (41.85 por ciento), por arma de fuego (25.58 por ciento), por arma blanca (16.27 por ciento). La principal etiología del trauma esplénico es la agresión (51.17 por ciento). El examen auxiliar más usado fue la ecografía abdominal (55.83 por ciento). Los traumas esplénicos grado III (27.90 por ciento) y IV (27.90 por ciento) fueron los más frecuentes, en el trauma esplénico grado IV y V existe predominio del shock hipovolémico con 9 pacientes (6.95 por ciento) cada uno, se hizo operatorio en 93 pacientes (72.09 por ciento), se realizó esplenectomía, en 60 pacientes (46.51 por ciento) el tratamiento quirúrgico fue más frecuente en el trauma esplénico grado IV (23.25 por ciento). La principal lesión asociada a trauma esplénico fue el trauma torácico 72 pacientes (55.81 por ciento). La estancia hospitalaria post cirugía fue de 13 días, las complicaciones son del 100 por ciento en los traumas de 5 o más órganos. En el manejo operatorio hubo complicaciones en 78 pacientes (60.46 por ciento). La morbilidad en esplenectomía por trauma es de 76.74 por ciento, mientras que la de causa médica es de 15 por ciento. CONCLUSIONES. La tomografía abdominal es el examen más importante como ayuda diagnóstica siempre en cuando el paciente se encuentre hemodinámicamente estable y no existan signos...

Blunt abdominal trauma requiring laparotomy in poly-traumatized patients

To investigate the impact of associated extra-abdominal injury on morbidity and mortality in poly-traumatized patients with blunt abdominal trauma. This analysis included poly-traumatized patients with blunt abdominal trauma treated at the Emergency Unit of Minia University Hospital and Misr University for Science and Technology Hospital, Minia, Egypt, between March 2006 and March 2008. This study included patients aged 4-73 years with injury severity score [ISS] more than 18 and indicated for surgical intervention. Data were analyzed with details of injury, treatment, complications, and mortality. Inclusion criteria were met by 94 patients with mean ISS of 29.3 +/- 6.4. Most frequent injuries were seen in the spleen [61.7%] and liver [47.9%]. Chest trauma represents most common extra-abdominal trauma [67%] Thirty-six patients [38.3%] died during their hospital stay. Most frequent reasons for death were hemorrhagic shock [27.8%], acute respiratory distress syndrome [27.8%], and head trauma [22.2%]. There was a positive relationship between liver injury and mortality, which not found in splenic injuries. Significantly more deaths were attributed to primarily extra-abdominal injuries [66.7%] and then to intra-abdominal injuries [19.4%]. In 5 patients [13.9%], a combination of intra- and extra- abdominal injuries caused post-traumatic death. Extra-abdominal injuries add to the morbidity and mortality from blunt abdominal trauma in poly-traumatized patients. Routine computerized tomography scanning can minimize negative abdominal exploration and facilitate better management of extra- abdominal injuries

Thoracic Splenosis: A Case Report and the Importance of Clinical History

We present a case of thoracic splenosis in a 42-yr-old man with a medical history of abdominal surgery for a penetration injury with an iron bar of the left abdomen and back. He had been in good condition, but a chest radiograph taken during a regular checkup showed a multinodular left pleura-based mass. Computed tomography (CT) showed that the mass was well-enhanced and homogeneous, indicating a sclerosing hemangioma. Following its removal by video-assisted thoracoscopic surgery, the mass appeared similar to a hemangioma, with marked adhesion to the left side diaphragmatic pleura and lung parenchyma. Frozen section showed that the lesion was a solid mass consisted with abundant lymphoid cells, suggesting a low grade lymphoma. On permanent section, however, the mass was found to be composed of white pulp, red pulp, a thick capsule and trabeculae and was diagnosed as ectopic splenic tissue, or thoracic splenosis. Review of the patient's history and chest CT at admission revealed that the patient had undergone a splenectomy for the penetration injury 20 yr previously.

Pseudoquiste esplénico gigante / Giant splenic pseudocyst

Se reportó una paciente asintomática a la que incidentalmente se le descubrió la presencia de esplenomegalia por tumoración de aspecto quístico del bazo; se le realizó esplenectomía e histológicamente se correspondió con un peudoquiste esplénico. Se concluyó que en el diagnóstico diferencial de una esplenomegalia hay que plantearse las lesiones quísticas y pseudoquísticas del bazo. La esplenectomía parcial o total es una opción terapéutica eficaz y permite la diferenciación entre quiste y pseudoquiste esplénico.

This is the case of a female asymptomatic patient, in whom incidentally authors discovered the presence of splenomegalia from splenic cystic tumor; a splenectomy was carried out that from the histological point if view corresponding to a splenic pseudocyst. We conclude that in differential diagnosis of a splenomegalia, we must to consider splenic cystic and pseudocystic lesions. Partial or total splenomegalia is a efficacious therapeutical option allowing differentiation between cyst and splenic pseudocyst.

Fatores prognósticos relacionados à falha do tratamento não-operatório de lesões esplênicas no trauma abdominal fechado / Prognostic factors related to non surgical treatment failure of splenic injuries in the abdominal blunt trauma

Objetivo: Identificar fatores prognósticos relacionados com a falha do tratamento não-operatório (TNO) de lesões esplênicas no trauma abdominal fechado. Métodos: Análise prospectiva de 56 pacientes adultos submetidos à TNO e divididos em um grupo de sucesso e outro de falha, que foi definida como necessidade de laparotomia por qualquer indicação. As lesões foram diagnosticadas por tomografia computadorizada e classificadas de acordo com os critérios da AAST (American Association for Surgery of Trauma). Os parâmetros estudados foram: na admissão - pressão arterial sistólica, frequências cardíaca e respiratória, nível de consciência (Escala de Glasgow) e RTS (Revised Trauma Score); durante a hospitalização – presença de lesões associadas, transfusão sanguíneae parâmetros hematológicos, tempo de internação e ISS (Injury Severity Score). Resultados: As falhas do TNO (19,6%) foram devidas à dor abdominal (45,4%), instabilidade hemodinâmica (36,4%), queda do volume globular associada a hematoma esplênico (9,1%) e abscesso esplênico (9,1%). Não foram observadas diferenças entre os grupos de sucesso e de falha nos dados na admissão. A taxa de falha de acordo com o grau da lesão esplênica foi 0% nos graus I e II agrupados; 17,5% nos graus III e IV agrupados e 80%no grau V (p = 0,0008). O uso de hemoderivados foi maior e mais frequente no grupo de falha (p=0,05). As relação do ISS (Injury Severity Score) com as taxas de falha foram 0% nos pacientes com ISS = 8; 15,9% nos com ISS entre 9 e 25, e 50% nos com ISS = 26 (p = 0,05). Não houve mortalidade e nem lesões de vísceras ocas despercebidas. Conclusão: O Injury Severity Score e grau da lesão esplênica relacionaram-se com a falha do tratamento não-operatório.

Objective: Identify prognostic factors related to treatment failure of blunt splenic injuries managed by non surgical treatment (NST). Methods: Fifty six adult patients submitted to NST were prospectively studied. The injuries were diagnosed by computed axial tomography scan and classified according to AAST (American Association for Surgery of Trauma) criteria. Patients were divided in success and failure groups. NST failure was defined as the need for laparotomy for any reason. Results: NST failures (19.6%) were due to: abdominal pain (45.4%), hemodinamic instability (36.4%), splenic haematoma associated to a fall in hematocrit (9.1%) and splenic abscess (9.1%). There were no failures in grade I and II of the splenic injuries; failure rate was 17.5% in grade III and IV injuries grouped, and 80% in grade V injuries (p = 0,0008). In the success group, 31.3% patients received red cell transfusions, versus 63.6% patients in the failure group (p = 0,05). Failure rate in patients with ISS = 8 was zero; 15.9% in patients with ISS 9 to 25; and 50% in patients with ISS = 26 (p = 0,05). There were no deaths or missed bowel injuries. Conclusion: ISS and splenic injury grade were related to failure of NST.