Factores pronósticos para pérdida de extremidad con trauma arterial periférico en un hospital de Colombia / Prognostic factors for extreme loss in peripheral arterial trauma at a Colombian hospital

INTRODUCCIÓN: El trauma vascular es un evento de baja frecuencia, con alta morbimortalidad que afecta la población joven; requiere en general un manejo quirúrgico. Se asocia a complicaciones desde la reintervención quirúrgica hasta la amputación de la extremidad, influenciado por variables tanto asociadas al trauma como a la atención hospitalaria. OBJETIVO: Determinar los factores de riesgo relacionados con amputación, en pacientes con trauma arterial periférico (TAP), atendidos en un Hospital de III nivel Huila- Colombia entre 2014-2017. MATERIALES Y MÉTODOS: Estudio observacional, analítico de corte retrospectiva con pacientes mayores de 13 años con TAP. RESULTADOS: Se incluyeron 79 pacientes, con un 1,56% de las consultas en nuestro Servicio de Urgencia. 89% hombres, promedio de edad 28,5 años. La principal comorbilidad fue la farmacodependencia 8,8%. El MESS (mangled extremity severity) promedio fue de 5,27 puntos y un tiempo critico de isquemia de extremidad > a 6 horas en el 38%. El mayor compromiso fue de miembros superiores, secundario a heridas por arma cortopunzante. La lesión predominante fue la transección arterial. Las principales complicaciones posquirúrgicas fueron la trombosis del vaso (21,5%) y la amputación (13,9%). Factores de riesgo asociados a amputación fueron la edad > 20 años, estancia hospitalaria > 7 días, MESS > 7 puntos, que presentaran como complicación quirúrgica la trombosis arterial y que requirieran reintervención quirúrgica. CONCLUSIONES: El trauma arterial periférico es una patología con gran repercusión socioeconómica y secuelas funcionales. Es necesaria la atención oportuna con tratamiento de las variables relacionadas con mal pronóstico, con el fin de disminuir las tasas de morbimortalidad.

INTRODUCTION: Vascular trauma is a low frequency event, with high morbidity and mortality that affects the young population; In general, it requires surgical management. It is associated with complications from surgical reintervention to amputation of the limb, influenced by trauma associated variables such as hospital care. AIM: Determine risk factors related to amputation, in patients with peripheral arterial trauma (TAP), treated at a Hospital of III level Huila-Colombia between 2014-2017. MATERIALS AND METHOD: Observational, retrospective analytical study with patients older than 13 years with TAP. RESULTS: We included 79 patients with an incidence of 1.56%. 89% men, average age 28.5 years. The main comorbidity was 8.8% drug dependence. The MESS (Mangled extremity severity) average was of 5.27 points and a critical time of limb ischemia > to 6 hours in 38%. The greater commitment was of superior members, secondary to injuries by sharp weapon. The predominant lesion was arterial transection. The main postoperative complications were vessel thrombosis (21.5%) and amputation in 13.9%. Risk factors associated with amputation were determined by age > 20 years, hospital stay > 7 days, MESS > 7 points, and that they presented arterial thrombosis as a surgical complication and finally required surgical reoperation. CONCLUSIONS: Peripheral arterial trauma is a pathology with great socioeconomic impact and functional sequelae. It is necessary the timely attention with treatment of the variables related to poor prognosis, in order to decrease the morbidity and mortality rates.

Versatilidad del colgajo libre anterolateral de muslo en la reconstrucción de defectos de cobertura en los miembros superiores e inferiores / Versatility of the anterolateral thigh free flap in the reconstruction of coverage defects

Introducción: El colgajo libre anterolateral de muslo es actualmente una de las opciones reconstructivas más útiles. Su versatilidad se debe a la inclusión de distintos tipos de tejido en diferentes combinaciones, una anatomía local confiable y un pedículo largo con un calibre adecuado. El objetivo de este estudio es revisar nuestra experiencia y evaluar la versatilidad del colgajo en defectos de los miembros superiores e inferiores. Materiales y Métodos: Estudio retrospectivo. Se consideraron pacientes tratados por defectos en las extremidades. Se analizaron variables preoperatorias, intraoperatorias y posoperatorias. Resultados: Se incluyeron 12 pacientes (7 hombres y 5 mujeres) con una edad promedio de 44 años. La causa del defecto fue resección oncológica (9 casos) y trauma (3 casos). La localización fue el miembro superior en cuatro casos y el miembro inferior en ocho pacientes. El tiempo promedio entre el defecto y la cirugía fue de 8 días. La tasa de supervivencia del colgajo fue del 92%, con falla en un caso. El sitio donante no presentó complicaciones, el cierre fue primario en 10 pacientes y con injerto de piel en dos. Conclusiones: El colgajo libre anterolateral de muslo es un recurso válido y de gran utilidad para la cobertura de defectos de diferentes etiologías tanto en los miembros superiores como en los miembros inferiores, ya que su versatilidad permite que se adapte con éxito en defectos de localización y tamaño variados. Nivel de Evidencia: IV

Introduction: The anterolateral thigh free flap is currently one of the most useful reconstructive options. A long pedicle with suitable vessel diameter, reliable anatomy and the availability of different tissues with large amounts of skin make this flap versatile. The purpose of this study was to evaluate the flap versatility in a series of patients with coverage defects in both, the upper and lower limbs. Methods: A retrospective study was performed. Inclusion criteria were patients with defects in the limbs to whom this flap was made as a reconstructive treatment. Preoperative, intraoperative and postoperative variables were analyzed. Results: Twelve patients (7 men and 5 women) with an average age of 44 years were included. Defects were caused by oncological resection (9 patients) and trauma (3 cases). In 4 cases the defect was in the upper limb and in 8 cases in the lower limb. The average time from the defect to the reconstructive surgery was 8 days. The survival rate of the flap was 92%, with only one failure. Donor site presented no complications and primary closure was performed in all cases, except for two requiring closure with skin graft. Conclusions: Anterolateral thigh free flap is a valid and very useful resource to cover defects of different etiologies in the upper and lower limbs since its versatility allows its successful adaptation in defects of varied location and size. Level of Evidence: IV

Colgajo paraescapular en pérdidas postraumáticas de tejidos blandos de las extremidades / Parascapular flap in post-traumatic soft-tissue loss at the limbs

Introducción: El objetivo de este artículo es comunicar los resultados obtenidos con el uso del colgajo paraescapular para cubrir defectos severos postraumáticos de tejidos blandos en las extremidades. Materiales y Métodos: Estudio retrospectivo, descriptivo, de una serie de 20 pacientes a los que se les realizó un colgajo libre paraescapular para cubrir lesiones masivas combinadas postraumáticas de tejidos blandos en las extremidades, entre 2006 y 2017. La edad de los pacientes promedió 30 años (18 hombres, 2 mujeres). La localización de las lesiones fue: 10 en antebrazo y muñeca, una en la región inguinal, siete en la pierna y dos en tobillo/pie. Resultados: El seguimiento promedio fue de 3.6 años. Se logró la cobertura exitosa en 17 casos. El tamaño de los colgajos promedió 24,8 x 10,7 cm. Seis casos presentaron lesiones vasculonerviosas que necesitaron injerto, seis se asociaron a pérdidas óseas, 11 requirieron injerto de piel y cuatro, reconstrucciones tendinosas. En todos los pacientes, el área donante cerró en forma primaria y sin secuelas funcionales. Dicho colgajo se combinó con el escapular en tres casos y con colgajo de dorsal ancho en tres casos. Dos colgajos fallaron y debió amputarse la extremidad lesionada; un paciente falleció por embolia masiva al séptimo día de la cirugía. Conclusiones: El colgajo paraescapular permitió salvar y reconstruir satisfactoriamente defectos masivos extensos en 17 de 20 extremidades, sin morbilidad para la zona donante del colgajo, pero su uso no está exento de complicaciones, y un abordaje multidisciplinario es necesario para disminuir esta morbilidad. Nivel de Evidencia: IV

Introduction: The aim of this paper is to present the results after the use of parascapular free flaps to cover severe softtissue defects at the extremities. Methods: A retrospective, descriptive study of 20 patients who received parascapular free flaps to cover massive combined soft-tissue lesions at the extremities as a salvage procedure from 2006 to 2017 was performed. Patients' age averaged 30 years (18 men, 2 women). Sites of lesions were: ten at the forearm and wrist, one at the inguinal region, seven at the leg and two at the ankle/foot. Results: Follow-up averaged 3.6 years. Successful coverage was achieved in 17 cases. Flap size averaged 24.8 x 10.7 cm. There were six cases with neurovascular lesions that needed grafting, six cases had associated bone loss, eleven patients needed skin graft and four required tendon reconstructions. Donor area closed primarily without functional limitations in all patients. In three cases the flap was combined with a scapular flap and in three cases with a latissimus dorsi flap. Two flaps failed and the injured limb was amputated; one patient died due to massive embolism seven days after surgery. Conclusions: Parascapular free flaps allowed salvage and reconstruction of 17 out of 20 severely injured limbs, without morbidity for the donor area. But its use is not free of complications, and a multidisciplinary approach is necessary to reduce this morbidity. Level of Evidence: IV

Cierre primario de fasciotomías con técnica con elásticos: experiencia nacional multicéntrica / Fasciotomy closure technique with vessel loops

Aim: Present and describe the progressive fasciotomy closure technique with vessel loops. Methods: Progressive and multicentric study in the period between June of 2007 and June of 2011. Results: In 2007 we initiated the complementary treatment for fasciotomy closure related to compartment syndrome or acute ischemia cases. Progressive closure with vessel loops, the shoelace technique. In 2010's preliminary report, we published a total of 56 fasciotomies closed by this technique, with an average closure time of 9.5 +/- 3.31 days. Current report is the result of a 4 years prospective study intending to prove that is possible to associate this technique to the initial management of fasciotomies closure. This final report shows a total of 122 fasciotomies cases closed in 7.9 +/- 3.31 days, without skin grafts. Conclusion: The technique is easy to learn, reproducible and not expensive. Results show that this technique is useful in reduce the time for fasciotomy closure.

Objetivos: Presentar y describir la técnica de cierre progresivo de fasciotomías con elásticos. Métodos: Estudio prospectivo multicéntrico realizado en Santiago de Chile entre junio de 2007 y junio de 2011. Resultados: En el año 2007 se inició un protocolo de manejo del cierre de las fasciotomías realizadas a pacientes portadores de síndrome compartimental o isquemia aguda de extremidades. Utilizando una técnica de entrelazado con elásticos vasculares se realizó el cierre de las fasciotomías. En el 2010 se publicó un reporte preliminar, presentando una serie de 56 fasciotomías cerradas con esta técnica, con un promedio de cierre de 9,5 +/- 3,31 días. La serie actual es el resultado de un estudio prospectivo de 4 años de duración que ha buscado demostrar que resulta posible asociar esta técnica con elásticos al manejo inicial del cierre de las fasciotomías. Nuestro reporte final muestra un total de 122 fasciotomías cerradas en un promedio de 7,9 +/- 3,31 días sin requerir de injertos de piel. Conclusiones: Presentamos una técnica quirúrgica fácil de reproducir, de bajo costo y con buenos resultados. El uso de elásticos vasculares muestra beneficios en el tiempo de cierre de las fasciotomías.

Comparative study of planned and unplanned excisions for the treatment of soft tissue sarcoma of the extremities

OBJECTIVE: Unplanned excision of soft tissue sarcomas is common because benign soft tissue lesions are very frequent. This study evaluated the impact of unplanned resections on overall survival, local recurrence and distant metastasis in patients with soft tissue sarcomas of the extremities. METHODS: In total, 52 patients who were diagnosed with soft tissue sarcomas between May 2001 and March 2011 were analyzed in a retrospective study. Of these patients, 29 (55.8%) had not undergone previous treatment and the remaining 23 (44.2%) patients had undergone prior resection of the tumor without oncological planning. All subsequent surgical procedures were performed at the same cancer referral center. The follow-up ranged from 6 to 122 months, with a mean of 39.89 months. Age, lesion size and depth, histological grade, surgical margins, overall survival, local and distant recurrence and adjuvant therapies were compared. RESULTS: Residual disease was observed in 91.3% of the re-resected specimens in the unplanned excision group, which exhibited greater numbers of superficial lesions, low histological grades and contaminated surgical margins compared with the re-resected specimens in the planned excision group. No differences were observed in local recurrence and 5-year overall survival between the groups, but distant metastases were significantly associated with planned excision after adjustment for the variables. CONCLUSIONS: There was no difference between patients undergoing unplanned excision and planned excision regarding local recurrence and overall survival. The planned excision group had a higher risk of distant metastasis, whereas there was a high rate of residual cancer in the unplanned excision group. .

Patient Preference and Satisfaction with Their Involvement in the Selection of an Anesthetic Method for Surgery

This prospective study aimed to evaluate the satisfaction of patients who participated in the decision-making process for selecting an anesthesia method for surgery; the patients' preferred role (active, collaborative or passive) in the decision-making; and the patients' preferred choice of anesthetic method. The study included 257 patients scheduled for simple elective surgeries involving the upper or lower extremities. During the preanesthetic visit, patients were informed regarding two methods of anesthesia for their surgeries, and participated in selecting one option. Of the 257 patients, 69.6% preferred a collaborative role, 18.3% and 12.1% preferred an active and a passive role, respectively. Among patients requiring surgery on an upper extremity and on a lower extremity, 64.3% and 51.3% expressed a preference for general anesthesia over regional anesthesia, respectively. After surgery, the majority of our patients were satisfied (93.4%) and felt respected (97.7%). Furthermore, the patients expressed a change in preference for assuming an active role (49.4%) and a collaborative role (43.6%) in the decision-making process for their future anesthesia needs. This study may help to promote patient centered care in a department of anesthesiology.

Midazolam versus ketamine in the management of emergence agitation in children undergoing lower abdominal and limb surgeries

Emergence agitation [EA] is a post-anesthetic problem which interferes with a child's recovery and presents a challenge in terms of assessment and management. In this study, we compared the effects of midazolam and ketamine as premedication in the management of EA in children aged 1-6 years. In this prospective, randomized clinical trial study, 58 children aged 1-6 years who were undergoing general anesthesia for elective surgery in Alzahra Hospital in Isfahan during 2008 until 2009. The patients were randomly assigned to receive 0.1 mg/kg midozolam [28] or 0.5 mg/kg ketamine [29] by IV route in the premedication room. All patients received a standardized anesthetic regimen and isoflurane was used for the maintenance of anesthesia. The incidence and severity of agitation [agitation score], severity of pain [pain score], anesthesia, recovery and extubation durations were recorded postoperatively. The prevalence of agitation in midazolam [21.4%] was lower than ketamine group [34.5%; P<0.05]. In addition, the duration of agitation in ketamine group [21 +/- 16.67 min] was significantly higher than midazolam group [6.83 +/- 6.55 min], [P<0.05]. However, no significant differences were seen in agitation score, pain score, anesthesia, recovery or extubation durations in the two groups [P>0.05]. The study showed that midazolam could reduce the frequency of agitation better than ketamine but both drugs were able to reduce the severity of agitation after short-time surgeries in young children

Extremity vascular trauma. A 7-year experience in Lahore, Pakistan

To determine the outcome of various techniques of vascular repair in terms of repair related complications and limb salavagibility. From January 1999 to December 2005, this retrospective study was conducted in the Department of General Surgery, Lahore General Hospital, Lahore, Pakistan. The patients, who underwent various surgical interventions for extremity vascular trauma, were included in this study. Those, who underwent primary amputation due to non-salvageable injuries or who presented with late complications of vascular injuries were excluded. Ninety-three patients underwent different surgical procedures for extremity vascular trauma. Majority of the patients were young, mean, 29.4 years male 91.3%. Penetrating trauma was the most common mode of injury 77.4%. The median time interval between injury and repair was 4.5 hours. Superficial femoral artery was the most frequently injured artery 26.8%. Graft repair was carried out in 41 patients 46.6%, while 34.1% of the patients had end-to-end anastomosis. Wound infection was the most common complication 18.2%. Seven patients 7.5% had secondary amputations and 3 3.2% died from other injuries. Vascular reconstruction was successful in 89.3% of the patients. Early revascularization by employing simple repair or interposition autogenous vein graft repair results in successful limb salvage with acceptable complication rate

Criterios de amputación de una extremidad lesionada / Amputation criteria of an injured extremity

Se revisaron y discutieron la fuerza, las debilidades y la validación clínica de los sistemas de evaluación, ya publicados, de una extremidad severamente lesionada. Se expusieron los sistemas de evaluación relacionados con la toma de decisión para la amputación o preservación de la extremidad lesionada. El sistema de puntuación de severidad de la extremidad lesionada (PSEL) se planteó es el que más se emplea por su fácil cálculo y seguridad.

The strength, weaknesses and clinical validation of the already published evaluation systems of a severely injured extremity were reviewed and discussed. The evaluation systems related to the decision making for the amputation or preservation of an injured extremity were exposed. The Mangled Extremity Severity Score (MESS) is the most used for its easy calculation and security.

O uso de curativos a vácuo como tratamento intermediário no trauma complexo de extremidade: experiência clínica e padronização da técnica / The use of vacuum dressing in intermediate treatment on complex traumac of extremitys: clinic experience and tecnic standardisation

Ferimentos com extensos danos aos tecidos e exposição de estruturas nobres, tradicionalmente, têmsido tratados com múltiplos procedimentos. O curativo a vácuo aplicado sobre uma lesão estáassociado à melhora da perfusão local, controle da infecção, diminuição do edema e proliferação do tecidode granulação. O curativo a vácuo é realizado utilizando-se técnicaasséptica, no centro cirúrgico, de maneira padronizada com materiais facilmente acessíveis e de baixo custo. Omesmo é trocado a cada 48h, sob anestesia e o tratamento definitivo, é realizado quando as condiçõeslocais da lesão forem favoráveis.Em todos os pacientes incluídos no protocolo deste trabalho obtiveram boa evolução, com resolução dainfecção, desenvolvimento de tecido de granulação, melhora da circulação local, possibilitando a execução do tratamento definitivo (retalhos ou enxertos). Dois dos pacientes que foram encaminhados com indicação de amputação do membro tiveram a função do membropreservada. O sucesso no tratamento dos pacientes submetidos ao curativo a vácuo demonstra a eficácia do método. Os materiais utilizados na confecção do mesmo possibilitaram uma grande economia uma vez que podemser adquiridos facilmente no comércio local e apresentam baixo custo. Tem-se como rotina no serviço onde seaplicou o protocolo, a utilização deste método em pacientes com lesões graves do membro inferior e superior.

Wounds with extensive damages to tissues and exposition of noble structures, traditionally, have beentreated with multiple procedures. The vacuum applied on an injury is associated with the improvement of the local perfusion, control of infection, reduction of edema and proliferation of the granulation tissue. The dressing is carried through using aseptictechnique, in the surgical center, in standardized way with easily accessible materials and of low cost. Each 48h itis changed under general anesthesia and the definitive treatment is carried through when the local conditions ofthe injury will be favorable. All patients in the protocol have been presentedwith good evolution, resolution of the infection, development of granulation tissue, improve of the local circulation, making possible the execution of the definitive treatment (free flaps or skin grafs). Two of the patients who had been proposed amputation of the member, had had the functionpreserved. The success in the treatment of the patients submitted to the vacuum demonstrates the effectivenessof this method. The materials used can be acquired easily in the local commerce and are cost effective. It is routinein the service of plastic surgery and reconstructive microsurgery at the Cristo Redentor Hospital, to use thismethod in patients with serious injuries of the inferior and superior member.

Estreptoquinase e oxigênio hiperbárico em congestão após reimplante de membro / Effects of streptokinase and hyperbaric oxygen therapy on venous occlusion after limb reimplantation in rats

OBJETIVO: Foram testados os efeitos do fármaco estreptoquinase e da terapia com oxigênio hiperbárico em modelo experimental de oclusão venosa após reimplante de membro. MÉTODOS: Foram realizadas amputações com preservação de vasos e nervos dos membros posteriores direitos de 140 ratos. Os grupos GM0, GM1, GM2, GM3 e GM4 foram submetidos a tempos de oclusão venosa de zero, uma, duas, três e quatro horas. Os grupos GE1 e GE2 foram tratados com estreptoquinase e terapia com oxigênio hiperbárico, respectivamente, após oclusão venosa de três horas. Os resultados foram analisados estatisticamente pelo teste do Qui-quadrado (p<0,05). RESULTADOS: As taxas de mortalidade transoperatórias dos grupos GM0, GM1, GM2, GM3 e GM4 foram 0 por cento, 10 por cento, 15 por cento, 30 por cento e 60 por cento e as pós-operatórias foram 5 por cento; 11,1 por cento; 11,7 por cento; 14,2 por cento e 100 por cento, respectivamente. As taxas de viabilidade dos membros isquêmicos após sete dias de avaliação foram 100 por cento, 87,5 por cento, 80 por cento e 66,67 por cento. As taxas de viabilidade dos grupos GE1 e GE2 foram 76,9 por cento e 100 por cento, respectivamente. As taxas de mortalidade transoperatórias foram diferentes estatisticamente com exceção de GM1 e GM2. As taxas de mortalidade pós-operatórias não foram diferentes com exceção de GM3 e GM4. As taxas de viabilidade dos grupos modelo foram diferentes entre si, exceto os grupos GM1 e GM2. GE1 resultou em uma viabilidade de membros sem diferença estatística e GE2 em uma viabilidade de membros maior que GM3. CONCLUSÃO: A estreptoquinase não alterou os efeitos da oclusão venosa e a terapia com oxigênio hiperbárico aumentou a viabilidade dos membros.

OBJECTIVE: The effectiveness of streptokinase and hyperbaric oxygen therapy on venous occlusion after limb reimplantation was tested in rats. METHODS: Amputation with preservation of vessels and nerves of the right hind limb was carried out in 140 rats. Groups MG0, MG1, MG2, MG3 and MG4 were submitted to 0, 1, 2, 3 and 4 hours of venous occlusion. MG3 was elected as control for the experimental groups. Groups EG1 and EG2 were submitted to 3 hours of venous occlusion and were treated with streptokinase and hyperbaric oxygen therapy. Limbs were observed for 7 days and their mortality and survival rates were studied. RESULTS: Trans-operatory mortality rates in groups MG0, MG1, MG2, MG3 and MG4 were 0, 10, 15, 30 and 60 percent respectively and the postoperatory mortality rates were 5; 11.1; 11.7; 14.2 and 100 percent respectively. The limb survival rates were 100 percent, 87.5 percent, 80 percent and 66.67 percent respectively and 76.9 percent and 100 percent in EG1 and EG2. Model groups were statistically different, except for MG1 and MG2 in trans-operatory mortality rates. There were no statistical differences in postoperatory mortality rates between model groups except for MG3 and MG4. Model groups were statistically different, with the exception of MG1 and MG2, in limb survival rates. EG1 and MG3 showed no statistical difference in limb survival and EG2 had a better limb survival than MG3. CONCLUSION: Results suggest that the administration of streptokinase does not change effects of venous occlusion and that hyperbaric oxygen therapy may decrease the effects of venous occlusion in limbs.

Peripheral vascular trauma an experience of two years

The incidence of vascular trauma has increased considerably during last 40 years. The study was carried out to describe the causes of injury, presentations, surgical approaches, outcome and complication of vascular trauma of the upper and lower limbs. This was a descriptive study. Surgical Department CMH Kharian, in which this study lasted from Oct 1997 to Oct 1999. In the study, 30 patients were operated for peripheral vascular injuries. Diagnosis was made by physical examination and hand Doppler alone. Primary vascular repair was carried out where possible; if not interposition vein graft was placed. Early liberal fasciotomy was considered as and when required. Patients with isolated venous trauma and patients with obviously unsalvageable lower extremity injury requiring primary amputation were excluded from the study. The limb salvage rate was 93.3%. A total no of 30 patients were included in this study. Out of these 24 [80%] were males and 6 [20%] were females, all were young adults with age ranging from 14 to 52 years, a mean age of 22 years and a standard deviation of. Gun shot wound [GSW] constituted the major cause of trauma and was present in 18 [60%] Patients, road traffic accident [RTA] in 6 [20%] patients and stab wound in 6 [20%] patients which are comparable to international studies. Primary end-to-end anastomosis was done in 20 [66.07%] patients and graft interposition was done in 10 [33.3%] patients. Vein graft was used in 20 [66.07%] patients lateral repair was done in 7 [23.3%] patients while in 3 [10%] patients ligation was performed. Early complications included bleeding in 2 [6.7%], thrombosis in 4 [13.3%] and wound infection in 3 [10%] patients respectively. Late complications are amputation in 2 [6.7%] patients and muscle ischaemia in 2 [6.7%] patients. Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present. Early fasciotomy is warranted if there is any suspicion of occurrence of compartment syndrome

Non iatrogenic pediatric vascular trauma

Arterial traumas in children present a challenging problem, even to experienced vascular surgeons. However, there is no consensus regarding the necessity of immediate surgical treatment for all such injuries in neonates and infants with non threatened extremities. Arterial injuries in school -aged subjects [age less than 6 years] are more easily handled. The aim of this study is to evaluate the results of repair of non iatrogenic vascular injuries in the pe-diatric age group. Fifteen patients with non iatrogenic vascular injuries were studied, [3] females and [12] males. Injury caused by gunshot, stab or blunt trauma. Seven injuries were in the lower limb, and eight injuries were in the upper limb, Age of the patients ranged between 3-14 years. Emergency repair was done for all patients according to the type of injury either by lateral sutures, end-to-end anastomosis, interposition vein graft, vein patch, or synthetic graft. In [14] patients distal pulses regained, All limbs were salvaged. Early exploration of all suspected vascular Injuries can be accomplished with excellent result

Management of arterial trauma of pediatric extremities [a report on 30 patients]

To review the diagnosis and treatment of children with upper and lower extremities arterial injuries and to evaluate the long-term outcome of long emgraft in pediatric aged group. A study of arterial trauma that needed surgery in children less than 13 years of age presented to Tanta University Hospital in the period from February 2001 to October 2005. Thirty [30] children were located who had arterial traumas distributed between lower extremity [20 cases] and upper extremity [10 cases]; exclusion criteria included isolated venous injuries, primary amputations. Clinical examination and duplex scanning were used for every patient at follow-up. Thirty children [24 boys and 6 girls] with an average age of 65 years [range, 3.5-13 years] were reviewed. The mechanisms of injury were blunt trauma in 20 patients [most of them were due to car accidents], penetrating injury in 10 cases. The most commonly injured arteries were 11 femoral, 6 popliteal, 5 brachial. An obvious delay in repair was evident in this series as 70% of cases [21 patients] were admitted to peripheral hospitals before reaching our center. Among 11 femoral injuries: 7 treated by long interposition graft [> 5cm] and 2 by femoropopliteal bypass to below knee segment. The material used for arterial repair were great saphenous vein [GSV] in 7 cases, the superficial femoral vein as an interposition graft in one case, and two parallel strips from contra-lateral GSV sutured together to obtain a wide lumen in another one In the popliteal segment: the use of intraluminal shunt and early fasciotomy to avoid ischemic nerve damage and decrease reperfusion injury, and then reconstruction with reversed saphenous interposition graft. Ligation of the bleeding infected pseudoaneurysm in the posterior tibial [1] and in the dorsalis pedis [1] was done. In the brachial: Three cases needed bypass either anatomical or extra-anatomical, and one in situ cephalic vein bypass, thrombectomy and dilatation through transverse arteriotomy was done in two cases. Saphenous interposition graft was done in 3 cases of the axillary and vein patch angioplasty in subclavian artery injury.. Most children had associated problems related to trauma especially bone fractures and soft tissue lacerations. Mortality rate in this series was 4 cases out of 30 cases [13.3%]. Delayed amputation needed for 3 cases [10%], two above knee amputations and one above elbow. At discharge all patients [22] had good distal pulse and functioning limb except one with brachial plexus injury. All patients advised to take aspocid 75 mg/daily. The patency of small diameter vein graft which was used as: long grafts in the remaining 12 cases, short graft or patch angioplasty in 5 cases were assessed. Only 12 patients completed the follow-up for 3 years. Duplex scanning showed no occlusion, non significant stenosis in two cases, no aneurysmal dilatation. Blunt trauma is more common than other causes in pediatric arterial injuries which masks the early diagnosis and makes the outcome poor. However, an aggressive vascular repair, innovative ideas, and expert vascular surgeon will allow limb salvage even in the presence of diagnostic delay. Invasive diagnostic studies have minimal role in these cases. Surgical repair can be performed in children and autogenous venous conduits are the best suitable bypass materials with patency and freedom from aneurysmal dilatation up to 3 years

Tratamiento quirúrgico de hemangiomas en niños / Surgical treatment of childhood hemangiomas

El hemangioma es la tumoración benigna más frecuente en pediatría, encontrándose en 12 por ciento de la población al año de vida. La controversia que existe en torno a estas lesiones se debe en gran parte a las diversas nomenclaturas que existen para una misma lesión que confunde el diagnóstico y su manejo futuro. La clasificación de Mulliken y Glowacki divide las lesiones vasculares en hemangiomas y malformaciones vasculares según su clínica y características endoteliales. Los hemangiomas corresponden a aquellas lesiones que tienen una fase de crecimiento rápido en el período neonatal, seguido de una fase lenta de involución espontánea. Por otra parte las malformaciones vasculares son lesiones que están presentes al nacer y que crecen con el niño sin regresar espontáneamente. La involución de los hemangiomas ocurre en 90 por ciento de los casos dentro de los 8 años, sin mediar tratamiento alguno. Sin embargo, existen condiciones como aquellas que involucran órganos vitales, que presentan riesgo de sangramiento o que comprometen zonas como naríz, párpados, etc., que hacen necesario tratarlas ya sea médicamente (corticoides, interferón, terapia de láser, embolización) o quirúrgicamente, para evitar secuelas estéticas y/o funcionales. Se analizan 70 pacientes con hemangiomas que fueron sometidos a tratamiento quirúrgico. El 71,4 por ciento estaban localizados en cabeza y cuello. El rango de edad de la cirugía fue de 3 meses a 15 años, siendo un procedimiento único en el 70 por ciento de los casos. El tratamiento quirúrgico evitó deformidad progresiva de las estructuras normales vecinas y/o trastornos psicológicos, proporcionándonos buenos resultados a largo plazo y mínima morbilidad

Limb salvage in malignant tumours of appendicular skeleton

A study was conducted at Jinnah Postgraduate Medical Centre, Karachi, to evaluate the results of various limb salvage techniques. Average age of the group of 12 subjects was 26.6 years and male to female ratio was 2.1. The histopathological diagnosis yielded recurrent GCT in 4 cases, chondrosarcoma in 3 cases, osteosarcoma, Ewing's sarcoma, parosteal osteosarcoma, adamantinoma and malignant fibrous histiocytoma in one case each. The surgical procedures included a wide variety of reconstructive methods. Adjuvant chemotherapy and radiotherapy were used where indicated. In terms of functional results, upper limb procedures scored 20.5 points [68%] and the lower limb procedures scored an average of 19 points [63%]. Local recurrence rate was 25%. Minimum follow up period was four years. Complications included recurrence in three patients, pulmonary metastasis, soft tissue implantation, deep infection, nonunion and graft absorption in one case each

Estudo comparativo entre a bupivacaína 0, 5 por cento e ropivacaína 0, 5 por cento isobáricas na anestesia subaracnóidea para cirurgia ortopédica / Isobaric 0, 5 per cent bupivacaine and 0, 5 per cent ropivacaine in spinal anesthesia for orthopedic surgery - a comparative study

Justificativa e objetivos: a ropivacaína é um anestésico local estruturalmente relacionado a bupivacaína. Embora a duraçäo e extensäo do bloqueio sensitivo sejam similares, a ropivacaína apresenta maior índice terapêutico por sua menor cardiotoxicidade. Apesar de empregada nos diversos métodos de anestesia regional, a sua utilizaçäo por via subaracnóidea tem sido ainda pouco explorada. O objetivo deste estudo foi comparar a qualidade do bloqueio sensitivo e motor entre a ropivacaína e a bupvacaína recêmica isobáricas a 0,5 por cento sem vasoconstrictor na raquianestesia para cirurgia ortopédica de membros inferiores. Método: participaram do estudo 30 pacientes com idade entre 16 72 anos, estado físico ASA I ou II, programados para cirurgia ortopédica eletiva de membros inferiores. Os pacientes foram divididos aleatoriamente em dois grupos de 15: grupo BUPI: (3ml - 15mg de bupivacaína racêmica a 0,5 por cento) e grupo ROPI: (3ml - 15mg - de ropivacaína a 0,5 por cento). Foram pesquisadas as características do bloqueio sensitivo e motor, bem como o aparecimento de efeitos colaterais. Resultados: näo houve diferenças significativas com relaçäo ao nível máximo de bloqueio sensitivo, nem com o tempo para atingi-lo. O tempo para aparecimento de dor näo estimulada na regiäo operada e a duraçäo do bloqueio motor foi menor no grupo da ropivacaína. Conclusäo: a ropivacaína a 0,5 por cento por via subracnóidea proporciona boa analgesia e bloqueio motor suficiente para finalidade cirúrgica

Disecciones aorticas: cirugía indirecta de las complicaciones isquémicas / Aortic dissections: indirect surgery in ischemic complications

Objetivo: exponer nuestra experiencia en la revascularización indirecta de las complicaciones isquémicas derivadas de disecciones aórticas y evaluación de la sobrevida de nuestros pacientes como un parámetro aproximado del resultado obtenido. Material y métodos: se conformó una serie de 22 pacientes intervenidos entre 1978 y 1998 por complicaciones isquémicas en región única y 8 con más de una región comprometida. Cuatro disecciones tipo A y 18 tipo B. Se clasificaron las disecciones mediante arteriografía por cateterismo axilar o femoral y a todos se les practicó estudio tomográfico. Resultados: la mortalidad operatoria (primer mes) fue de 22,7 por ciento ñ 8,9. La sobrevida acumulada fue de 77,3 por ciento ñ 8,9 al primer mes, disminuyendo a 72,7 por ciento ñ 9,5 al segundo, a 68,2 popr ciento ñ 9,9 al tercero, resultando de 55,7 por ciento ñ 11,7 a los 24 meses. La sobrevida en 5 pacientes con isquemia solamente en miembros inferiores fue del 100 por ciento operatoria y 75 por ciento ñ 22 a 24 meses, mientras que en pacientes con isquemia mesentérica y/o renal fue 71 por ciento ñ 11 y 53 por ciento ñ 12, respectivamente (p=ns). Los pacientes con insuficiencia renal recuperaron la función. No se realizó ninguna amputación de miembro inferior. Conclusión: la tasa de mortalidad operatoria con cirugía indirecta (22,7 por ciento; 4,9 por ciento a 40,5 por ciento según intervalo de confianza 95 por ciento) resultó menor a la cirugía directa según bibliografía consultada (50 por ciento; p<0,05)

Doppler a color (dúplex) comparado con flebografía en el diagnóstico de trombosis venosa profunda después de cirugá ortopédica mayor de miembros inferiores / Colour Doppler (duplex) comparison to phlebography in diagnosis of deep venous thrombosis, after major orthopaedic surgery in lower limbs

La trombosis venosa profunda (TVP) es una complicación frecuente en cirugía ortopédica de miembros inferiores. Las modalidades diagnósticas con que se cuenta actualmente muestran limitaciones como baja sensibilidad y especificidad. El dúplex ha sido utilizado en años recientes con considerables ventajas. El presente trabajo estudió 110 pacientes sometidos a cirugía ortopédica de miembros inferiores en el periodo comprendido del 1o. de septiembre de 1997 al 30 de mayo de 1998, se utilizó como profiláctico para TVP enoxaparina subcutánea a dosis de 40 miligramos diarios por promedio de 10 días. Fue un estudio prospectivo, longitudinal y comparativo entre dúplex y flebografía como métodos diagnósticos. Los resultados obtenidos demostraron una incidencia de TVP de miembros inferiores de 9.09 por ciento. De 10 pacientes diagnósticados con TVP, solo cuatro (40 por ciento) presentaron datos clínicos. Hubo tres falsos negativos y tres falsos positivos con dúplex, lo que no representó diferencia estadística significativa con la flebografía (p=0.61). La sensibilidad del dúplex fue del 70 por ciento y expecificidad del 90.9 por ciento. El tiempo quirúrgico prolongado resultó tener relación directa con la aparición de TVP (p=0.001). El uso de torniquete neumático no demostró correlacionarse con la incidencia de TVP (p=0.42)