Traumatismo anorrectal contuso. Reporte de un caso y revisión bibliográfica / Blunt anorectal trauma. Case reportand literature review

Introducción: El traumatismo anorrectal es una causa poco frecuente de consulta al servicio de emergencias, con una incidencia del 1 al 3%. A menudo está asociado a lesiones potencialmente mortales, por esta razón, es fundamental conocer los principios de diagnóstico y tratamiento, así como los protocolos de atención inicial de los pacientes politraumatizados. Método: Reportamos el caso de un paciente masculino de 47 años con trauma anorrectal contuso con compromiso del esfínter anal interno y externo, tratado con reparación primaria del complejo esfinteriano con técnica de overlapping, rafia de la mucosa, submucosa y muscular del recto. A los 12 meses presenta buena evolución sin incontinencia anal. Conclusión: El tratamiento del trauma rectal, basado en el dogma de las 4 D (desbridamiento, derivación fecal, drenaje presacro, lavado distal) fue exitoso. La técnica de overlapping para la lesión esfinteriana fue simple y efectiva para la reconstrucción anatómica y funcional. (AU)

Introduction: Anorectal trauma is a rare cause of consultation to the Emergency Department, with an incidence of 1 to 3%. It is often associated with life-threatening injuries, so it is essential to know the principles of diagnosis and treatment, as well as the initial care protocols for the polytrau-matized patient. Methods: We present the case of a 47-year-old man with a blunt anorectal trauma involving the internal and external anal sphincter, treated with primary overlapping repair of the sphincter complex and suturing of the rectal wall. At 12 months the patient presents good outcome, without anal incontinence. Conclusion: The treatment of rectal trauma, based on the 4 D ́s dogma (debridement, fecal diversion, presacral drainage, distal rectal washout lavage) was successful. Repair of the overlapping sphincter injury was simple and effective for anatomical and functional reconstruction. (AU)

Lesión traumática expuesta, compleja y grave de tibia, tratada con fijador externo Álvarez Cambras / Exposed, complex and severe traumatic injury of the tibia treated with Alvarez Cambra external fixation

RESUMEN Con el paulatino incremento de accidentes automovilísticos, de trabajo, y la violencia urbana, las fracturas expuestas y complejas constituyen traumatismos de creciente incidencia y de difícil solución, con largos períodos de convalecencia que ponen en peligro la vida o la conservación del miembro lesionado. Un gran número de ellas dejan secuelas invalidantes. Existen varios tratamientos, entre ellos la fijación externa, utilizando el sistema creado por el profesor Rodrigo Álvarez Cambras, con varias ventajas que proporcionan una mejor evolución. Se realizó este trabajo con el objetivo de mostrar la evolución y los resultados de un paciente ingresado y operado con el diagnóstico de lesión expuesta, compleja y grave de la extremidad inferior, específicamente de tibia. Este presentó varias complicaciones, por lo que se le colocó un aparato de osteosíntesis de fijación externa Álvarez Cambras en el Hospital Provincial Clínico Quirúrgico Docente José Ramón López Tabrane, de Matanzas (AU).

ABSTRACT With the gradual increase of automobile and work accidents as well as urban violence, exposed and complex fractures are traumas of increasing incidence and difficult solution, with long periods of convalescence that endanger the life or the conservation of the injured member. A large number of them leave invalidating sequels. There are several treatments, including external fixation using the system created by Professor Rodrigo Alvarez Cambra, with several advantages that provide a better evolution. The current work was carried out with the objective of showing the evolution and results of a patient who entered the Teaching Provincial Clinical-surgical Hospital Jose Ramon Lopez Tabrane, of Matanzas, and underwent a surgery with the diagnosis of exposed, complex and serious lesion in the lower limb, specifically of tibia. The patient had several complications and so he was put an Alvarez Cambra external fixation osteosynthesis devise (AU).

Manejo quirúrgico de heridas por mordeduras de perro en pacientes pediátricos: nuestra experiencia en 8 años / Surgical management of dog bite wounds in pediatric patients: our experience in 8 years

Introducción. Hasta un 90% de las mordeduras de animales son producidas por perros. Los niños son la población más vulnerable frente a las mordeduras ya que suelen afectar una mayor proporción de superficie corporal. Objetivo. Analizar la casuística de mordeduras de perro y su repercusión en nuestro entorno. Métodos. Estudio observacional, descriptivo, retrospectivo de un período de 8 años, que incluyó a todos los pacientes de 0 a 18 años con diagnóstico de mordedura de perro. Resultados. Se incluyeron 183 pacientes con diagnóstico de mordedura de perro. El promedio de edad fue de 6,1 años, y el grupo etario más afectado fue el de los niños de 3 a 5 años (38,3%). El tratamiento quirúrgico fue dividido en pacientes que requirieron rafia por planos (84,6%), colgajos (11,4%), injertos (3,4%) y puntos de aproximación (1%). Se reportaron 8 pacientes con complicaciones (4,4%). Conclusión. Los niños de 3 a 5 años son los más afectados por mordeduras de perro y la zona de cabeza y cuello es la más común. Un porcentaje importante de pacientes requirieron colgajos e injertos con buenos resultados.

Introduction. Up to 90% of animal bites are produced by dogs. Children are the most vulnerable population because bites tend to affect greater body surface area. Outcome. Analyze dog bites cases and their impact on our environment. Methods. An observational, descriptive, retrospective study during an 8 year period was carried out, which included all patients from 0 to 18 years with a diagnosis of dog bite. Results. A total of 183 patients with a diagnosis of dog bite were found. The average age was 6.1 years, and the age group most affected was children from 3 to 5 years old (38.3%). Surgical treatment was divided into: patients who required suture by planes (84.6%), flaps (11.4%) and grafts (3.4%) and approximation stitches (1%). Complications were reported in 8 patients (4.4%). Conclusion. Children from 3 to 5 years old are the most affected by dog bites, the head and neck area is the most common. A significant percentage of patients required flaps and grafts with good results.

Trauma urbano moderno en Caracas / Modern urban trauma in Caracas

A principios del nuevo milenio surgió el concepto del "Trauma urbano moderno", sustentando en la experiencia de varios conflagraciones en zonas densamente pobladas. Fue definido como un conflicto violento, cerrado, con heridas destructivas y de difícil acceso para su evacuación. Su manejo incluyo el cuestionamiento de viejos dogmas y la incorporación de nuevas estrategias. El motín del reten "La Planta", el incremento en las detonaciones por granadas fragmentarias y los graves enfrentamientos entre bandas delictivas o contra cuerpos de seguridad, en diversas zonas de Caracas indican el establecimiento de una modalidad mas agresiva de violencia. Los cirujanos capitalinos se enfrentan con más frecuencia a lesiones severas y múltiples. El personal medico requiere la adecuada comprensión y preparación para afrontar este nuevo tipo de heridas. La reciente enfermedad Covid 19 representa un desafió agregado en el abordaje de los pacientes con traumatismos(AU)

The experience in many combats in densely populated urban areas, determined the new concept of "Modern urban warfare" in the beginning of the new millennium. This definition is a warfare violent, close-quarter, with destructive injuries and the delayed of evacuation. New innovations were incorporate. The revolt in the "La Planta" prison, the increase of grenades explosions and engagement between criminal organized, in many zones of Caracas, illustrated this new definition. The venezuelans surgeons attended many severe and multiple injuries. The surgical personal need understand this new kind of injuries. The new disease Covid 19 represents a challenge in the attention of these patients(AU)

Lesiones precordiales: reporte de dos casos / Precordial injuries: report of two cases

Las heridas precordiales son una entidad poco frecuente y desafiante en cirugía de trauma en los servicios de Emergencia. La incidencia elevada de taponamiento y trauma cardiaco, así como su alta mortalidad obliga a tomar decisiones diagnósticas y terapéuticas rápidas y precisas. Material y Métodos: se presentan los casos de dos pacientes masculinos que ingresaron al servicio de Emergencia del Hospital Roosevelt con lesiones precordiales penetrantes con trauma pericárdico y cardiaco, con diferentes manifestaciones clínicas a los que se les realizó ventana pericárdica subxifoidea diagnóstica y seguido una esternotomía media con exposición pericárdica y cardiaca como abordaje y tratamiento quirúrgico definitivo. Discusión: Es de suma importancia reconocer los amplios escenarios de presentaciones clínicas del paciente con heridas en la región precordial y mantener un alto índice de sospecha de trauma y taponamiento cardiacos en todas las lesiones precordiales penetrantes en pacientes estables e inestables para no retrasar el diagnóstico y tratamiento quirúrgico temprano y adecuado. Las lesiones asociadas y complicaciones trans y postoperatorias aumentan la mortalidad de estos pacientes (AU)

Precordial wounds are rare and challenging lesions in Trauma Services. The high incidence of cardiac trauma and the high mortality requires fast and precise diagnostic and therapeutic decisions. Case report: Two male patients who were admitted to the Roosevelt Hospital Emergency Service with penetrating precordial injuries with pericardial and cardiac trauma are presented, with different clinical manifestations, who underwent a diagnostic subxiphoid pericardial window and a median sternotomy with pericardial and cardiac exposure as a definitive surgical approach and treatment. Discussion: Is important to recognize the broad scenarios of patients with wounds in the precordial region and to maintain a high index of suspicion of cardiac trauma and tamponade in all penetrating precordial injuries inclusive in stable patients to not delay diagnosis and treatment and a proper surgical intervention. Associated injuries and perioperative complications increase the mortality of these patients

Lesión quirúrgica de la vía biliar: experiencia en el Hospital José Ramón Vidal de Corrientes / Bile duct injury after cholecystectomy: the experience of Hospital José Ramón Vidal de Corrientes

RESUMEN Antecedentes: la lesión quirúrgica de la vía biliar representa un gran problema de salud y puede surgir ante cualquier cirujano que realice una colecistectomía. Objetivos: el objetivo del trabajo fue presentar nuestra experiencia en reparación de la vía biliar, ana lizando la morbimortalidad y la incidencia de dicha patología en nuestro Servicio. Material y métodos: estudio retrospectivo descriptivo; se tomaron las variables de las historias clínicas de los pacientes en un período de 8 años, de enero de 2011 a julio de 2019 donde fueron admitidos 19 pacientes que presentaron lesión quirúrgica de la vía biliar en el Hospital José Ramón Vidal de la provincia de Corrientes, Argentina. Resultados: 12 pacientes fueron tratados quirúrgicamente mediante hepático-yeyuno anastomosis, 2 por bihepático-yeyuno anastomosis y dos mediante sutura término-terminal bilio-biliar sobre tubo de Kehr. Tres pacientes fueron tratados mediante colocación de stent y dilatación posterior mediante colangiopancreatografia retrógrada endoscópica. Conclusión: los cirujanos deben entrenarse para disminuir al mínimo la posibilidad de una lesión. El objetivo de una colecistectomía debería ser no lesionar la vía biliar.

ABSTRACT Background: Bile duct injury represents a serious health problem and can occur after any cholecystectomy. Objectives: The aim of this study was to report our experience in repairing bile duct injuries analyzing morbidity, mortality and its incidence in our department. Material and Methods: We conducted a retrospective and descriptive study. The information was retrieved form the medical records of 19 patients with bile duct injury hospitalized at the Hospital José Ramón Vidal, Corrientes, Argentina, between January 2011 and July 2019. Results: A Roux-en-Y hepaticojejunostomy was performed in 12 patients, double hepaticojejunostomy in two patients, and two patients were treated with end-to-end ductal anastomosis with suture over a T tube. Three patients underwent endoscopic retrograde cholangiopancreatography with stent placement and dilation. Conclusion: Surgeons should be trained to avoid the possibility of bile duct injury. The main goal of cholecystectomy should be to avoid this complication.

Tratamento cirúrgico de hemangioma infantil nasal e labial na fase involuída: relato de caso / Surgical treatment of infantile nasal and labial hemangioma in the involuted phase: a case report

Hemangioma infantil (HI) é o tumor vascular mais comum e a neoplasia benigna mais frequente da infância, com maior incidência no sexo feminino e na população branca. Quase 60% dos casos ocorrem em cabeça e pescoço, sendo o tratamento ativo durante a fase proliferativa mais frequentemente indicado, em decorrência dos possíveis problemas funcionais e do potencial desfigurante. Relatamos um caso de paciente com hemangioma infantil involuído de ponta nasal e lábio superior, tratado de forma expectante durante a infância, submetida à correção da deformidade residual com técnicas de rinoplastia, associado à zetaplastia e lipoenxertia do lábio superior com bom resultado e satisfação do paciente.

Infantile hemangioma (IH) is the most common vascular tumor and the most frequent benign neoplasm in childhood, with the highest incidence in females and the white population. Almost 60% of cases occur in the head and neck, and active treatment during the proliferative phase is the most frequently indicated, due to possible functional problems and disfiguring potential. We report a case of a patient with involute infantile hemangioma of the nasal tip and upper lip, treated expectantly during childhood, submitted to residual deformity correction with rhinoplasty techniques, associated with zetaplasty and upper lip grafting with good results and patient satisfaction.

Lesiones traumáticas más frecuentes producidas en 2 centros de detención penitenciario, un estudio observacional / Most frequent traumatic injury in 2 prison detention centers, an observational study

Resumen Introducción Las cárceles constituyen un foco de violencia inherente y un ambiente propicio de lesiones traumáticas. Objetivo Describir el perfil de ingreso y evolución de personas privadas de libertad hospitalizadas en nivel terciario por trauma acontecido en 2 complejos penitenciarios, que ingresan a nuestro Servicio. Materiales y Método Estudio descriptivo, incluyó la revisión de fichas clínicas en nuestro hospital (HUAP), durante el periodo entre agosto de 2009 y diciembre de 2016. Resultados 88 consultas de personas privadas de libertad, donde se obtuvieron 46 consultas por lesiones traumáticas. Se observó una distribución simétrica para las variables edad, presión arterial media, frecuencia cardíaca, hematocrito, hemoglobina y recuento de leucocitos. El sitio del trauma más frecuente fue el tórax y el abdomen (incluyendo cara anterior y posterior completa), cada uno con 18 pacientes (39,13% cada uno). El diagnóstico de ingreso más frecuente fue neumotórax en doce sujetos. Los principales tratamientos efectuados fueron 16 laparotomías exploradoras (34,78; IC 95%: 22,68 a 49,23) y 12 pleurostomías (26,09; IC 95%: 15,60 a 40,26). La duración de la hospitalización distribuyó en forma asimétrica, con mediana de 3 días. Tuvimos 6 reingresos (13,04%) en los primeros 30 días posteriores al alta y una mortalidad. Conclusiones Los hechos de violencia en estos 2 centros penitenciarios en Santiago, son un diagnóstico que se presenta en la urgencia de nuestro hospital, con lesiones de distinta gravedad y tratamiento. Resulta necesario adelantarse a estos escenarios, donde ahora sabemos que gran parte de ellos necesitará algún procedimiento o intervención.

Background Prisons are a source of inherent violence and an environment conducive to traumatic injuries. Aim The objective of this paper is to describe the income and evolution profile of hospitalized people deprived of liberty at the tertiary level due to trauma that occurred in two prison detention centers in Santiago, that enters our service. Materials and Method Descriptive study, included the review of clinical records in our hospital, during the period between August 2009 and December 2016. Results 88 consultations of people deprived of liberty, where 46 consultations for traumatic injuries were obtained. A symmetric distribution was observed for the variables age, mean arterial pressure, heart rate, hematocrit, hemoglobin and leukocyte count. The most frequent trauma site was the thorax and abdomen (including front face and full back), each with 18 patients (39.13% each). The most frequent diagnosis of admission was pneumothorax in twelve subjects. The main treatments were 16 exploratory laparotomies (34.78, 95% CI: 22.68 to 49.23) and 12 pleurostomies (26.09, 95% CI: 15.60 to 40.26). The duration of hospitalization distributed asymmetrically, with a median of 3 days. We had 6 readmissions (13.04%) in the first 30 days after discharge and one mortality. Conclusions The violence in this two prison detention centers, in Santiago, is a diagnosis that appears in the urgency of our hospital, with lesions of different severity and treatment. It is necessary to anticipate these scenarios, where we now know that a large part of them will need some procedure or intervention.

Major trauma and severe burn: a synergistic mortality: case report and literature review / Traumatismo grave y quemadura severa: una mortalidad sinérgica: reporte de un caso y revisión bibliográfica

CASE PRESENTATION: A 42-year-old man was transferred to our institution after a highenergy accident (an explosion). He presented second-degree burns on 20% of the total body surface area (TBSA), affecting the lower hemiabdomen and the lower right limb. He also presented a supraintercondylar open fracture of the right femur (Gustilo I). The burns were treated with debridement and coverage withmesh graft, while the fracture required an early transitory transarticular external fixation with delayed definitive osteosynthesis. Our patient presented good local and systemic evolution. We can offer a eleven-month follow-up. DISCUSSION: The literature supports that the combination of trauma and burn injuries is a relatively rare pattern, which may explain the lack of knowledge and studies on this subject. This double injury has demonstrated a synergistic effect on mortality. The management of soft tissues in the coexistence of an open fracture and a burn in the same limb is a challenge. The method and timing of the treatment of the fracture directly impacts the treatment of the burn (and vice versa), and most authors tend to treat the fracture first. All of the studies reviewed emphasized the importance of the multidisciplinary approach. CONCLUSIONS: We have presented a complex case combining major trauma and severe burns. Although there is a lack of studies in the literature on this subject, the papers state that this is an unusual pattern with a synergistic effect on mortality. In our experience, the management of soft tissues and the multidisciplinary approach play a central role, as it is also stated in the literature. The management of these patients is still controversial, and more studies are needed.

PRESENTACIÓN DEL CASO: Hombre de 42 años trasladado a nuestra institución tras un accidente de alta energía (explosión). Presentaba quemaduras de segundo grado del 20% de la superficie corporal total (SCT), afectando el hemiabdomen inferior y la extremidad inferior derecha. También presentaba una fractura abierta supraintercondílea de fémur derecho (Gustilo I). Las quemaduras fueron tratadas mediante desbridamiento y cobertura mediante injerto mallado, mientras que la fractura requirió un fijador externo transarticular precoz de forma transitoria con una osteosíntesis definitiva diferida. Nuestro paciente presentó buena evolución local y sistémica. Podemos ofrecer un seguimiento a 11 meses. DISCUSIÓN: La bibliografía defiende que la lesión combinada de traumatismo y quemadura es un patrón relativamente raro, pudiendo explicar la falta de conocimiento y publicaciones al respecto. Este doble insulto ha demostrado un efecto sinérgico en la mortalidad. El manejo de las partes blandas cuando coexisten una fractura abierta y una quemadura en la misma extremidad es un desafío. El método y el momento de tratamiento de la fractura impactan de forma directa en el tratamiento de la quemadura (y viceversa); y la mayoría de los autores tienden a tratar en primer lugar la fractura. Todos los estudios analizados enfatizan la importancia del abordaje multidisciplinario. CONCLUSIONES: Hemos presentado un caso complejo combinando traumatismo grave y quemaduras severas. Aunque haya una falta de bibliografía, los estudios afirman que se trata de un patrón inusual con un efecto sinérgico sobre la mortalidad. En nuestra experiencia, el manejo de las partes blandas y el abordaje multidisciplinario tienen un rol central, tal y como defienden también los artículos publicados. El manejo de estos pacientes sigue siendo controvertido, y son necesarios más estudios.

Vena cava inferior como factor predictor del shock en trauma: medición ecográfica / Inferior vena cava as a predictor of shock in trauma patients: sonographic measurement

Resumen Objetivo Establecer la medición ecográfica del diámetro de la vena cava inferior como factor predictor del shock en pacientes politraumatizados. Materiales y Método Estudio de corte transversal donde se determinó la medición ecográfica de la vena cava inferior a 40 pacientes que ingresaron a la Unidad de Politraumatizados (UPT) del Hospital General del Este "Dr. Domingo Luciani", en el período entre enero y abril de 2018. Se seleccionaron 2 grupos; el grupo 1: pacientes en shock , aquellos con tensión arterial sistólica menor a 90 mm Hg al ingreso, y el grupo 2: pacientes controles que mantuvieron cifras tensionales normales. El estudio de imagen de la vena cava inferior se realizó con el equipo de ecografía ALOKA prosound SSD-a5 y con el ultrasonido portátil MicroMaxx SonoSite , en el cual se midió el índice de colapsabilidad. Los hallazgos se registraron en la hoja de recolección de datos. El análisis estadístico se hizo con la prueba de t de student para muestras independientes y la valoración de puntos de corte diagnóstico se hizo con la prueba de ROC. Resultados La media del Índice de colapsabilidad (IC) de la VCI para el grupo control y de shock fue de 26 ± 12,7% y de 58,5 ± 5,9%, respectivamente; El índice de colapsabilidad fue > 50% en todos los pacientes del grupo de shock . Conclusiones La medición del diámetro de la VCI es un predictor de shock , siendo el IC el parámetro más sensible y específico.

Aim To establish the sonographic measurement of the diameter of the inferior vena cava as a predictor of shock in trauma patients. Materials and Method A cross-sectional study to determined the sonographic measurement of the inferior vena cava to 40 patients attended at Hospital Domingo Luciani trauma unit, in the period between January and April of 2018. Two groups were selected; group 1: shock patients, those with systolic blood pressure lower than 90 mm Hg, and the group 2: control patients that kept normal blood pressure. The image study of the inferior vena cava was carried out with the ALOKA prosound ultrasound equipment SSD a5 and with the portable ultrasound MicroMaxx SonoSite, in which the collapsibility index was measured. The findings were recorded in the data collection sheet. The statistical analysis proposed for the comparison of averages was made with the student's t-test for independent samples and the assessment of diagnostic cut-off points was made with a ROC curve. Results the mean of collapsability index of de IVC for control and shock group were 26 ± 12,7% and 58,5 ± 5,9%, respectively; The collapsability index (CI) was > 50% in all patients of shock group. Conclusions The measurement of the ICV diameter is a predictor of shock, being the IC the most sensitive and specific parameter.

Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project / Análise da custo-efetividade em hernioplastias antes e após a implementação do projeto ACERTO

ABSTRACT Objective: to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital. Methods: retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System. Results: surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction). Conclusion: there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

RESUMO Objetivo: comparar custos hospitalares e desfechos clínicos em hernioplastias inguinal e incisional antes e após a implementação do projeto ACERTO, em hospital universitário. Métodos: estudo retrospectivo com 492 pacientes submetidos à hernioplastias inguinais (n=315) ou incisionais (n=177). A investigação envolveu duas fases: entre janeiro de 2002 e dezembro de 2005, englobando casos internados antes da implantação do protocolo ACERTO (período PRÉ-ACERTO), e outra, com casos operados entre janeiro de 2006 e dezembro de 2011, após a implantação (período ACERTO). A variável de desfecho principal foi o custo médio de internação comparando-se os dois períodos estudados. Como desfecho secundário, analisou-se tempo de internação, infecção de sítio cirúrgico e mortalidade. Foi utilizado o método de custeio do Sistema de Informação de Custos do Setor Público. Resultados: a ocorrência de infecção de sítio cirúrgico foi maior (p=0,039) na primeira fase do estudo tanto para hernioplastias inguinais (2 (1,6%) versus 0 (0%) casos) quanto para incisionais (5 (7,6%) versus 3 (2,7%) casos). O tempo de internação diminuiu em um dia após a implementação do protocolo ACERTO (p=0,005). Houve redução no custo por paciente indo de R$ 4.328,58 por paciente na 1ª fase para R$ 2.885,72 na 2ª fase (redução de 66,7%). Conclusão: o conjunto de dados mostrou que houve redução da morbidade infecciosa, tempo de internação e custos hospitalares em hernioplastias após a implementação do protocolo ACERTO.

Trauma quality indicators: a way to identify attention points in the treatment of elderly trauma patients / Filtros de qualidade: uma maneira de identificar pontos de atenção no atendimento ao idoso traumatizado

ABSTRACT Purpose: to trauma quality indicators as a tool to identify opportunities of improvement in elderly trauma patient's' treatment. Methods: prospective analysis of data collected between 2014-2015, and stored in the iTreg software (by Ecossistemas). Trauma victims, aged older than 60 years and trauma quality indicators were assessed, based on those supported by SBAIT in 2013: (F1) Acute subdural hematoma drainage after 4 hours from admission, in patients with GCS<9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours from extubation; (F4) Admission-laparotomy time greater than 60 min. in hemodynamically uinstable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours from admission; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time greater than 6 hours; (F10) Surgery after 24 from admission. The indicators, treatments, adverse effects and deaths were analyzed, using the SPSS software, and the chi-squared and Fisher tests were used to calculate the statistical relevance. Results: from the 92 cases, 36 (39,1%) had complications and 15 (16,3%) died. The adequate use of quality indicator's were substantially different among those who survived (was of 12%) compared to those who died (55,6%). The incidence of complications was of 77,8% (7/9) in patients with compromised indicators and 34,9% (28/83) in those without (p=0.017). Conclusions: trauma quality indicators are directly related with the occurrence of complications and deaths, in elderly trauma patients.

RESUMO Objetivo: analisar a utilidade de "filtros de qualidade" pré-estabelecidos para a identificação de oportunidades de melhora no atendimento ao idoso traumatizado. Método: análise prospectiva dos dados coletados entre 2014-2015 e armazenados em software iTreg (Ecossistemas). Foram revisados vítimas de trauma maiores de 60 anos e filtros de qualidade propostos, baseados naqueles idealizados pela SBAIT em 2013: (F1) Drenagem de hematoma subdural agudo após 4 horas da admissão em pacientes com ECG<9; (F2) transferência da sala de emergência sem via aérea definitiva e ECG<9; (F3) Reintubação em até 48 horas da extubação; (F4) Tempo admissão-laparotomia exploradora maior que 60 min. em pacientes instáveis com foco abdominal; (F5) Reoperação não programada; (F6) Laparotomia após 4 horas da admissão; (F7) Fratura de diáfise de fémur não fixada; (F8) Tratamento não operatório de ferimento abdominal por PAF; (F9) Tempo admissão-tratamento de fraturas expostas de tíbia superior a 6 horas; (F10) Operação após 24 horas da admissão. Foi analisada relação dos filtros com tratamentos, complicações e óbitos, pelo software SPSS, utilizando-se o teste qui-quadrado e Fisher para calcular a relevância estatística. Resultados: dos 92 casos, 36 (39,1%) tiveram complicações e 15 (16,3%) morreram. A frequência da quebra dos filtros foi de 12% em pacientes que sobreviveram e 55,6% nos entre os que faleceram (p=0,005). A incidência de complicações foi de 77,8% (7/9) nos doentes com FQ comprometido, contra 34,9% (28/83) nos não comprometidos (p=0,017). Conclusões: o comprometimento dos filtros de qualidade se relaciona diretamente com a ocorrência de complicações e óbitos em idosos traumatizados.

Retalho interósseo posterior reverso do antebraço para o tratamento cirúrgico do trauma elétrico da mão: relato de caso / Reverse posterior interosseous flap of the forearm for the surgical treatment of electric hand trauma: Case report

Introdução: Lesões que acometem as mãos com importante perda cutânea frequentemente requerem retalhos para cobertura precoce, visto que permitem melhor reabilitação. Dentre as opções, o retalho interósseo posterior reverso do antebraço é o mais utilizado para defeitos no dorso da mão e punho, com baixas taxas de complicações. Normalmente, esse retalho não é utilizado para a reconstrução de defeitos em região palmar, já que geralmente não alcança esse local. Relato de caso: Apresentamos o caso de um paciente com queimadura elétrica de terceiro grau, em palma da mão direita, cuja reconstrução foi realizada com o uso do retalho interósseo posterior reverso do antebraço, após debridamentos conservadores, no 14o dia após a queimadura. O paciente apresentou boa evolução pós-operatória, sem complicações ou sequelas funcionais a longo prazo. Conclusão: O retalho interósseo posterior reverso do antebraço permite cobertura adequada de lesões em palma da mão, preservando sua funcionalidade.

Introduction: Lesions affecting the hands with significant skin loss often require flaps for early coverage, as these permit faster healing. Among the various options, the reverse posterior interosseous flap of the forearm is most commonly used for defects involving the back of the hand and wrist due to low complication rates. Normally, this flap is not used for the reconstruction of defects in the palmar region since its distal reach is insufficient. Case report: We present the case of a male patient with third-degree electrical burns on his right palm, whose reconstruction was performed on the 14th day postinjury using the reverse posterior interosseous flap of the forearm after conservative debridement. The patient presented good postoperative evolution, without long-term complications or functional sequelae. Conclusion: The reverse posterior interosseous flap of the forearm permits adequate coverage of palm injuries, preserving its functionality.

Tratamento para queloides: revisão de literatura / Treatment of keloids: a literature review

Introdução: Queloides surgem de resposta excessiva à lesão da derme, resultando em proliferação de fibroblastos, produção exagerada de colágeno e comprometimento da pele sadia adjacente. O diagnóstico é clínico e muitos métodos conservadores e cirúrgicos já foram utilizados para tratamento. Porém, dados da eficácia desses tratamentos são limitados e não há consenso na literatura quanto a melhor técnica a ser empregada, permanecendo uma lacuna que necessita ser preenchida, a fim de que seus usos sejam indicados com maior confiabilidade, em um modelo de medicina baseada em evidências. Métodos: Revisão não sistemática da literatura sobre "queloides" nas bases de dados PubMed, Scielo, MEDLINE, UptoDate e livros-texto das áreas de Dermatologia e Cirurgia Dermatológica. Revisão de Literatura: Foram enumeradas e abordadas as principais informações sobre técnicas cirúrgicas e adjuvantes empregadas para essas lesões, que são: excisão, injeções intralesionais, crioterapia, laserterapia, revestimento com gel de silicone, radioterapia e pressoterapia. Torna-se relevante o levantamento dessas informações, tendo em vista que, além de poder causar dor, prurido e restrição de movimento, o principal motivo da procura de assistência médica para queloide é devido ao aspecto cosmético/estético, e as taxas de reincidência e falha terapêutica ainda são altas, sendo necessário conscientizar o paciente sobre o procedimento e seus efeitos. Conclusão: São muitos os tratamentos disponíveis para o queloide, sejam cirúrgicos ou não, todavia não há consenso sobre uma abordagem universalmente aceita. São necessários mais estudos, com a finalidade de definir a melhor conduta e atingir melhores resultados, visto a qualidade mediana das evidências apresentadas nos estudos.

Introduction: Keloids are characterized by an abnormal response to dermal trauma, resulting in fibroblast proliferation, excessive collagen production, and impairment of adjacent healthy tissue. The diagnosis is clinical, and many conservative and surgical methods can be used as treatments. However, data on the efficacy of these treatments are limited, and there is no consensus regarding the best treatment option. This gap needs to be filled by developing comprehensive evidence-based therapies. Methods: A non-systematic literature review of keloid scars was carried out using PubMed, Scielo, MEDLINE, UptoDate, and dermatology and dermatological surgery textbooks. Literature review: The search retrieved relevant information on surgical and adjuvant therapies used for keloids, including excision, intralesional injections, cryotherapy, laser therapy, silicone gel sheeting, radiation therapy, and pressure therapy. These data are crucial because, in addition to complaints of pain, itching, and restriction of movement, the main reason for seeking treatment for keloids is for cosmetic and aesthetic improvement, and the rates of recurrence and treatment failure are high, emphasizing the importance of creating awareness regarding the available procedures and their effectiveness. Conclusion: Many surgical and adjuvant therapies for keloids are available. Nonetheless, there is no consensus on a universally accepted treatment. Therefore, additional high-quality studies are needed to identify the most effective therapeutic approaches to achieve better results.

Uso de dermis artificial (Integra®) en reparación de lesiones traumáticas extensas de cuero cabelludo / Use of artificial dermis (INTEGRA®) in repair of extensive traumatic scalp injuries

Resumen Objetivo: Presentar 4 casos clínicos en los cuales el uso de dermis artificial Integra® resultó ser una solución segura y confiable para defectos de cuero cabelludo. Materiales y Método: Revisión de fichas clínicas de pacientes ingresados al Departamento de Cirugía Plástica y Quemados del Hospital del Trabajador de Santiago con diagnóstico de lesión traumática extensa de cuero cabelludo entre los años 2005-2013 que se resolvieron con uso de Integra®. Resultados: 4 pacientes de sexo femenino con lesión traumática que comprometían entre 70-98% de la superficie de cuero cabelludo, tiempo promedio entre aplicación de Integra® e injerto dermoepidérmico fue 18 días con 100% de cobertura; solo hubo complicaciones menores (ulceración crónica de vertex y dolor neuropático). El tiempo promedio de alta laboral fue 368 días, usando órtesis capilar. Discusión: La cobertura inmediata del tejido es fundamental para la reconstrucción exitosa del cuero cabelludo. Aparte del tejido autólogo, la dermis artificial constituye una alternativa para la reconstrucción rápida del cuero cabelludo con excelentes resultados. Conclusiones: Integra® es una solución segura y confiable para reconstruir defectos complejos del cuero cabelludo.

Aim: To present 4 clinical cases in which the use of artificial dermis (Integra®) turned out to be a safe and reliable solution for scalp defects. Materials and Method: review of clinical records of patients admitted to the Department of Plastic Surgery and Burns of the Hospital of the Worker of Santiago with a diagnosis of extensive traumatic injury of the scalp between the years 2005-2013 that were resolved with use of Integra®. Results: 4 female patients with traumatic injury that compromised between 70-95% of the surface of scalp, average time between application of integra and dermoepidermal graft was 18 days with 100% coverage; there were only minor complications (chronic vertex ulceration and neuropathic pain). The average time of high labor was 368 days, using capillary orthosis. Discussion: The immediate coverage of the tissue is essential for the successful reconstruction of the scalp. Apart from autologous tissue, the artificial dermis is an alternative for rapid reconstruction of the scalp with excellent results. Conclusions: Integra is a safe and reliable solution to reconstruct complex defects of the scalp.

Evisceración abdominal postraumática en un niño / Post-traumatic abdominal evisceration in a child

Introducción: Se considera un paciente politraumatizado aquel que presenta dos o más lesiones, de las que al menos una puede comprometer su vida o vaya a originar secuelas invalidantes. Una conducta inicial adecuada puede reducir la mortalidad de pacientes como el que se presenta, pues la atención inicial debe ser ordenada y sistemática; siempre se deben identificar y tratar con prioridad, las lesiones que comprometen la vida del paciente. Objetivo: Presentar un caso, que por su interés y singularidad en el mecanismo de acción, expone la secuencia de actuación que se llevó a cabo por cirujanos generales, fuera de un servicio de cirugía pediátrica. Caso clínico: Se reporta el caso de un paciente masculino de 6 años de edad, que acude al cuerpo de guardia politraumatizado y presenta una avulsión músculo cutánea abdominal con evisceración intestinal, al sufrir caída en movimiento con traumatismo abdominal penetrante con biela de pedal de una bicicleta. A pesar de no contar en la institución de atención, con servicio de cirugía pediátrica, se impuso la cirugía de emergencia por las condiciones del paciente. Conclusiones: Luego de laparotomía inicial con reconstrucción de la pared abdominal y cierre primario con puntos de seguridad, el paciente evolucionó de forma estable. Fue remitido para un servicio de terapia intensiva pediátrica, donde y evolucionó sin complicaciones, hasta su egreso(AU)

Introduction: A polytraumatized patient is considered to be one who presents two or more injuries, of which at least one may compromise his life or cause disabling sequelae. An adequate initial behavior can reduce the mortality of patients such as the one that occurs, because the initial attention must be orderly and systematic, the lesions that compromise the patient's life must always be identified and treated with priority. Objective: To present a case, which due to its interest and uniqueness in the mechanism of action, exposes the sequence of action that was carried out by general surgeons, outside of a pediatric surgery service. Clinical case: We report the case of a 6-year-old male patient who came to emergency, polytraumatized and presenting an abdominal skin muscle avulsion with intestinal evisceration, he suffered a fall during movement with penetrating abdominal trauma with a bike pedal crank. Despite not having a pediatric surgery service in the attending institution, emergency surgery was imposed due to the patient's conditions. Conclusions: After the initial laparotomy with reconstruction of the abdominal wall and primary closure with security points, the patients evolves in a stable way, he was referred to a pediatric intensive care service, where he evolved without complications until discharge(AU)

Sutura elástica: uma opção no tratamento de extensas perdas cutâneas / Elastic suture: a treatment option for extensive skin loss

Em meio a tantos desafios aos quais os cirurgiões plásticos são impostos quando se trata de grandes perdas cutâneas, faz-se necessário o desenvolvimento de diferentes métodos de fechamento de grandes feridas. Assim sendo, foi realizada a técnica da sutura elástica em dois pacientes do Hospital Independência do grupo Divina Providência em Porto Alegre, uma alternativa que se demonstrou rápida, eficaz e de baixo custo. A técnica é dividida em duas etapas, a primeira com a sutura elástica propriamente dita - na qual consiste na maior aproximação dos bordos com auxílio de um elástico -, e a segunda com o fechamento da pele já aproximada pela fase anterior. Assim sendo, com o uso da técnica nesses dois pacientes, foi possível concluir que a sutura elástica é uma técnica de fechamento simples, com grande segurança e funcionalidade para aproximação de bordos de grandes feridas, evitando, em alguns casos, o uso de técnicas mais complexas.

Extensive skin loss presents major challenges for plastic surgeons, making it necessary to develop different techniques to close extensive wounds. In this context, the elastic suture technique was performed in two patients at the Independência Hospital of the Divina Providência Group in Porto Alegre. This alternative technique was fast and effective and had a low cost. The technique is divided into two stages: the elastic suture itself, which consists of the approximation of the wound edges with the aid of an elastic band; and closure of the skin already approximated in the previous stage. The elastic suture is a highly safe and simple closure technique with the ability to approximate the edges of extensive wounds, avoiding the use of more complex techniques in some cases.

Análise epidemiológico-evolutiva de pacientes submetidos a cirurgia plástica reparadora em um hospital de referência em trauma / Epidemiological-evolutional analysis of patients submitted to plastic reconstructive surgery in a trauma reference hospital

Introdução: Lesões decorrentes de trauma são agravos súbitos à saúde que podem levar a deficiências temporárias e interferir na qualidade de vida das vítimas. O serviço de Cirurgia Plástica Reparadora (CPR) do Hospital Metropolitano de Urgência e Emergência (HMUE) atua como a unidade de referência no tratamento de feridas dos pacientes vítimas de trauma no Estado do Pará. Métodos: Estudo observacional analítico, do tipo transversal prospectivo. A população foi composta por 78 pacientes atendidos no período de dezembro de 2015 até dezembro de 2016. Resultados: A população predominante foi de pacientes do sexo masculino, autônomos, entre 21 a 30 anos. Os acidentes automobilísticos foram os mais prevalentes. A área corporal mais afetada foi a dos membros inferiores e o tipo de cirurgia mais realizada foi enxerto. Tanto entre os pacientes submetidos à cirurgia de enxerto quanto os de retalho, predominou a viabilidade no intervalo de 90-100%. Não foi verificada associação significativa da faixa etária dos pacientes sob o grau de viabilidade. Houve relação entre o número de dias do acidente até a intervenção com o grau de viabilidade do enxerto. Conclusão: Os pacientes internados no hospital no mesmo dia do acidente têm seis vezes mais chance de apresentar viabilidade do enxerto acima de 80% e, portanto, desfecho favorável.

Introduction: Injuries due to trauma are health problems that can lead to temporary deficiencies and interfere with the quality of life of the victims. The Reconstructive Plastic Surgery (RPS) service of the Metropolitan Emergency and Emergency Hospital (HMUE) acts as the reference unit for the treatment of wounds of trauma victims in the State of Pará. Methods: An observational cross-sectional study. The population was composed of 78 patients attended in the period from December 2015 to December 2016. Results: The predominant population was male patients, between 21 and 30 years old. Automobile accidents were the most prevalent. The most affected body area was the lower limbs and the type of surgery performed was graft. Among the patients submitted to graft surgery as well as those of the graft, the viability predominated in the range of 90-100%. There was no significant association between the age of the group under the degree of viability. There was a relation between the number of days of the accident and the intervention with the degree of viability of the graft. Conclusion: Patients hospitalized on the same day of the accident are six times more likely to present graft viability than 80%.

Variação anatômica do tronco celíaco e do sistema arterial hepático: uma análise por exames de imagem / Anatomical variations of the celiac trunk and the hepatic arterial system: an imaging analysis

Introdução: As variações anatômicas das artérias hepáticas e do tronco celíaco são de grande importância para cirurgias laparoscópicas, transplantes hepáticos, intervenções radiológicas e tratamento de lesões abdominais. O grande aumento de intervenções minimamente invasivas deixou os atos cirúrgicos com menos espaço para o reconhecimento de estruturas anatômicas. Métodos: Foi realizado um estudo retrospectivo do banco de dados do Hospital São Vicente de Paulo durante o ano de 2016, analisando imagens abdominais de tomografia computadorizada com contraste e angiotomografias que envolvem a aorta abdominal e seus ramos ­ um total de 461 imagens foram analisadas. Resultados: Dos 461 pacientes analisados, 86,9% apresentaram a conformação usual do tronco celíaco ­ cuja anatômica é a origem tríplice com as artérias gástrica esquerda, esplênica e hepática comum e artéria mesentérica superior se originando sozinha da aorta abdominal. Dentre as anatomias anômalas (13%), o padrão mais comum desses ramos foi a presença em 4,5% de um tronco hepatomesentérico e um tronco gastroesplênico. No sistema arterial hepático a conformação mais prevalente foram as artérias hepáticas direita e esquerda sendo ramos da hepática próprias em 66,3%. Das alterações anatômicas (33,2%), as mais comuns foram a presença de uma artéria hepática esquerda acessória ramo da artéria gástrica esquerda (7,8%). Conclusão: Variações anatômicas do sistema arterial hepático e do tronco celíaco são prevalentes, podendo apresentar diversos arranjos organizacionais. (AU)

Introduction: Anatomical variations in the hepatic arteries and the celiac trunk are of great importance for laparoscopic surgeries, liver transplants, radiological interventions and treatment of abdominal injuries. A large increase in the number of minimally invasive interventions hampered the recognition of anatomical structures in surgical procedures. Methods: A retrospective study was performed using the 2016 São Vicente de Paulo Hospital database of contrast-enhanced abdominal computed tomography images and computed tomography angiographies showing the abdominal aorta and its branches. In total, 461 images were analyzed. Results: Of the 461 patients analyzed, 86.9% had usual conformation of the celiac trunk, which trifurcates into the left gastric artery, the common hepatic artery and the splenic artery, while the superior mesenteric artery originates alone from the abdominal aorta. Among the cases of anomalous anatomy (13%), the most common pattern in these branches was the presence of a hepatomesenteric trunk and a gastrosplenic trunk in 4.5%. In the hepatic arterial system, the most prevalent conformation was the right and left hepatic arteries being branches of the hepatic artery proper in 66.3%. Of all anatomical variations (33.2%), the most common were the presence of a left accessory hepatic artery of the left gastric artery (7.8%). Conclusion: Anatomical variations in the hepatic arterial system and the celiac trunk are common, having different structural arrangements. (AU)