Terapia endovascular en trauma periférico: una alternativa a la cirugía abierta tradicional / Endovascular therapy in peripheral trauma: our experience

Resumen Introducción: La terapia endovascular ha demostrado ser una buena alternativa de tratamiento en las enfermedades arteriales y venosas. Asimismo, en trauma vascular periférico constituye una excelente opción, especialmente en sitios anatómicos difíciles de acceder y con lesiones complejas como seudoaneurismas, fístulas arteriovenosas (FAV) o la combinación de ambos, con numerosas ventajas. Objetivo: Evaluar los resultados del tratamiento endovascular en trauma vascular penetrante por agresiones y iatrogenias. Materiales y Método: Revisión retrospectiva de todos los pacientes con trauma vascular periférico sometidos a terapia endovascular. Resultados: Entre abril de 2011 y mayo de 2020 se trataron 30 pacientes, 28 hombres y 2 mujeres. Con edades fluctuantes entre 17 y 84 años. La causa del trauma fue 20 penetrantes y 10 iatrogenias. Los vasos afectados fueron arteria femoral superficial 6, femoral profunda 2, subclavia 9, axilar 1, poplítea 4, ilíacas 1, peronea 1, tibial anterior 5, tronco venoso braquiocefálico 1. Diecisiete pacientes fueron tratados con endoprótesis, 9 con embolización y 4 con cierre percutáneo en relación con catéteres arteriales en subclavia. No hubo mortalidad, pero dos pacientes requirieron reparación abierta: un seudoaneurisma poplíteo gigante y un seudoaneurisma de tibial anterior, en ambos se constató sección completa de ambas arterias. El seguimiento clínico ha sido entre 30 días y 3 años. Conclusiones: En esta serie de casos, la terapia endovascular en lesiones de trauma vascular periférico ofrece excelentes resultados con baja morbimortalidad y permeabilidad aceptable a corto y mediano plazo.

Introduction: Endovascular therapy has proven to be a good treatment alternative in arterial and venous diseases. Likewise, in peripheral vascular trauma it is an excellent option, especially in anatomical sites that are difficult to access and with complex lesions such as pseudoaneurysms, arteriovenous fistulas (AVFs) or the combination of both, with numerous advantages. Aim: To evaluate the results of endovascular treatment in trauma Penetrating vascular injury and iatrogenesis. Materials and Method: Retrospective review of all patients with peripheral vascular trauma undergoing endovascular therapy. Results: Between April 2011 and May 2020, 30 patients were treated, 28 men and 2 women. With fluctuating ages between 17 and 84 years. The cause of the trauma was 20 penetrating and 10 iatrogenic. The affected vessels were superficial femoral artery 6, deep femoral 2, subclavian 9, axillary 1, popliteal 4, iliac 1, peroneal 1, anterior tibial 5, brachiocephalic venous trunk 1. Seventeen patients were treated with endoprosthesis, 9 with embolization and 4 with percutaneous closure in relation to arterial catheters in the subclavian. There was no mortality but two patients required open repair: a giant popliteal pseudoaneurysm and an anterior tibial pseudoaneurysm in which both sections of both arteries were found to be complete. Clinical follow-up was between 30 days and 3 years. Conclusión: In this serie, endovascular therapy in peripheral vascular trauma lesions offers excellent results with low morbidity and mortality and acceptable patency in the short and medium term.

Desgarro perineal con mucosa vaginal íntegra tras primera relación sexual / Perineal tear with intact vaginal mucosa after first sexual intercourse

RESUMEN Las lesiones del tracto genital femenino tras relaciones sexuales son un problema frecuente en las urgencias de ginecología, pero poco estudiado salvo su aspecto médico-legal. Su incidencia es desconocida ya que muchas mujeres no llegan a consultar por miedo o pudor. El reconocimiento precoz de estas lesiones y su correcto tratamiento puede evitar la parición de secuelas que acompañarán a nuestra paciente durante el resto de su vida. Presentamos el caso de una paciente de 18 años con un desgarro perineal con mucosa vaginal íntegra tras su primera relación sexual.

ABSTRACT Injuries to the female genital tract after sexual intercourse are a frequent problem in gynecological emergencies, but little studied except for their medico-legal aspect. Its incidence is unknown since many women do not go to their specialist out of fear or embarrassment. Early recognition of these injuries and their correct treatment may prevent the appearance of sequelae that will accompany our patient for the rest of her life. We present the case of an 18-year-old patient with a perineal tear with intact vaginal mucosa after her first sexual intercourse.

Heridas penetrantes cardíacas: comentario a propósito de una publicación de 1945 / Penetrating heart wounds: comments about a 1945 publication

A raíz de una publicación de 1945, se realiza una revisión acerca de las heridas penetrantes cardíacas: Los conceptos que han resistido el paso del tiempo, los que han cambiado, y las nuevas tendencias. Se compara con la publicación de hace 70 años y se ofrecen algunas conclusiones...

Following a 1945 publication, a brief review about penetrating heart wounds is performed: The concepts that have stood the test of time, those have changed, and the new trends. We compare with the publication of 70 years ago and offer some conclusions...

Heridas penetrantes del cuello / Penetrating wounds of the neck

This is a revision based in a personal experience of the penetrating wounds of the neck, describing the diagnosis and treatment.

An unusual case of total ophthalmoplegia.

An eight-year-old male child presented with drooping of the left eyelid with a history of penetrating injury of hard palate by an iron spoon seven days ago, which had already been removed by the neurosurgeon as the computed tomography scan revealed a spoon in the left posterior ethmoid and sphenoid bone penetrating into the middle cranial fossa. On examination, visual acuity was 20/20 in each eye and left eye showed total ophthalmoplegia. Oral cavity revealed a hole in the left lateral part of the hard palate. We managed the case with tapering dose of systemic prednisolone. The total ophthalmoplegia was markedly improved in one month. Cases of foreign bodies in the orbit with intracranial extension are not unusual, but the path this foreign body traveled through the hard palate without affecting the optic nerve, internal carotid artery or cavernous sinus makes an interesting variation.

Laparoscopic repair of penetrating injury of the diaphragm: an experience from a district hospital

In this study we review our experience in using laparoscopy as a diagnostic and therapeutic tool in dealing with penetrating diaphragmatic injuries due to stab wounds and look at the feasibility of using this procedure in other similar institutions. Thirty patients, all of whom were males 20-30 years of age, presented to the surgical emergency unit of our hospital with upper abdominal and lower chest wall stab wounds between 01-05-1998 and 30-11-2006. Diagnosis of the diaphragm injury was either obvious with omentum herniating through the chest wall, or occult with confirmation of the injury at laparoscopy. All patients underwent diagnostic laparoscopy, which resulted in identification and efficient treatment of eight patients with diaphragmatic injury, and thereby laparotomy was avoided. The procedure converted to open surgery in one patient because of a small left-sided colonic tear. Laparoscopy is an efficient tool for the diagnosis and management of diaphragmatic injuries. It should be used routinely instead of exploratory laparotomy in haemodynamically stable patients with penetrating lower chest injuries

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds: [review]

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Spectrum and outcome of pancreatic trauma.

BACKGROUND AND AIMS: Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. METHOD: Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. RESULTS: The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. CONCLUSIONS: Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.

Penetrating neck trauma and the aberrant subclavian artery

Vascular injuries from penetrating trauma to the base of the neck are accompanied by significant morbidity and potential mortality. These injuries require several diagnostic adjuncts in order to facilitate early diagnosis and appropriate treatment. Herein reported is the case of a patient who sustained penetrating injury to the thoracic inlet but had a fortuitous anomaly that prevented vascular injury and its attendant complications.

Microlaparoscopia en trauma penetrante de abdomen procedimiento en la sala de emergencia con anestesia local / Minilaparoscopy in penetrating abdominal trauma emergency room procedure with local anesthesia

ANTECEDENTES: En el trauma penetrante de abdomen, existe un número de laparotomías innecesarias, con un porcentaje de complicaciones no despreciable. Cuando se identifica lesión del peritoneo, debe ser evaluada la exploración quirúrgica del abdomen. OBJETIVO: Evaluar la penetración del peritoneo, utilizando un método de diagnostico de visión directa. LUGAR DE APLICACIÓN: Hospital de Urgencias de Córdoba. Hospital de trauma. DISEÑO: Se realizó laparoscopia con anestesia local en pacientes con heridas penetrantes de abdomen, que no presentaran evidencias de injuria de órganos intraabdominales en los estudios de imágenes y los cuales se planteaban dudas en el examen físico, para evidenciar lesión del peritoneo. Estudio retrospectivo. POBLACION: Pacientes con trauma penetrante de abdomen, tratados entre mayo de 2004 y enero de 2005, con diagnostico dudoso de violación peritoneal. METODO: Con sedación y anestesia local a nivel umbilical,se coloco un laparoscopio de visión directa, de 5mm y 90°, con el cual se pudo observar todo el peritoneo anterior, los flancos y el diafragma, buscando la herida peritoneal o líquido libre. RESULTADOS: En cuatro pacientes pudo evitarse la laparotomía. Los cuatro restantes se convirtieron a cirugía abierta o videolaparoscopía, de los cuales dos presentaban lesión de víscera hueca, uno hemoperitoneo y otro lesión hepática mínima. No hubo complicaciones en ambos grupos. La estadía del primer grupo fue 13 horas de promedio. CONCLUSIONES: En pacientes seleccionados, la minilaparoscopía resultó útil en disminuir el porcentaje de laparotomías innecesarias y anestesia general y sus complicaciones.

BACKGROUND: There are a number of unnecessary laparotomies in penetrating trauma, with a non worthless percentage of complications. When the peritoneal injury is identified, surgical exploration of the abdomen should be evaluated. OBJECTIVE: Evaluate the penetration of the peritoneum, using a diagnose method with direct vision. SETTING: Hospital de Urgencias de Córdoba. Trauma Hospital. DESIGN: To evidence peritoneum trespassing, laparoscopy was performed with local anaesthesia in patients with penetrating abdominal trauma without signs of abdominal injury in the imaging methods and doubts in the physical examination, in a prospective setting. POPULATION: Patient with penetrating abdominal trauma, treated between May 2004 to January 2005, with doubtful diagnose of peritoneal violation. METHOD: Under sedation and local anaesthesia, a 5 millimetres laparoscope with 90 degrees vision was placed at umbilicus. The anterior abdominal wall, flanks and diaphragm were exanimate, looking for the peritoneal wound or free fluid. RESULTS: Laparotomy could be avoided in four patients. In the four remaining, laparoscopy or conventional surgery was performed. Two presented hollow viscera injury, one hemoperitoneo and the other, minimum liver damage. There were not complications in both groups. The average hospital stay of the first group was 13 hours. CONCLUSIONS: In selected patients, the minilaparoscopy is useful in decreased the percentage of unnecessary laparotomies and general anaesthesia, and its complications.

Heridas penetrantes cardíacas / Penetrating wound of the heart

a) The greater number of cases of hearts wounds due to stabs belong in first place to Turkey and secondly to Chile b) We present two cases in which heart operations were realized with good results in our hospital. The operated cases are in good health and working c) In our country the most frequent cases of wounds caused by steel weapons, affected the right ventriculed) Traumatized people like these, will fall like fulminated, or faint with the sensation of fear, showing alarmingly the symptoms of shock and hemorrhage e) Opportunity of transport and the immediate operation are as important as the operation itself Pleural Complications regulary accompany nearly all cases

Heridas penetrantes abdominales en el Hospital Clínico Regional de Valdivia entre los años 2001-2003 / Penetrating abdominal wounds in the clinic regional hospital of Valdivia from 2001-2003 years

Se presentan 124 casos de heridas penetrantes abdominales, en revisión retrospectiva desde enero 2001 hasta diciembre 2003, excluyendo las heridas toracoabdominales. Afectaron predominantemente al sexo masculino (95.1 por ciento), relacionándose en forma directa con la ingesta de alcohol en el 75 por ciento de los casos. La etiología más frecuente fue el arma blanca (93.5 por ciento). Las manifestaciones clínicas cardinales fueron: signos peritoneales (34.6 por ciento), dolor abdominal (33 por ciento), fiebre (19.3 por ciento), exteriorización de epiplón (14.5 por ciento) y signos y síntomas de shock (11.2 por ciento). El 63.7 por ciento de los individuos afectados fue operado y hubo un 8,9 por ciento de laparotomías en blanco. En el grupo de pacientes que no requirió cirugía, el tiempo promedio de observación previo al alta fue 23 horas. En el grupo de operados el tiempo promedio de observación, previo a la cirugía, fue 5 horas, la profilaxis antibiótica se efectuó en el 91.1 por ciento y el esquema más usado fue Penicilina, Quemicetina y Gentamicina i.v. (44.3 por ciento). Los órganos más lesionados fueron intestino delgado (44.3 por ciento) y colon (20,3 por ciento); la técnica quirúrgica más empleada correspondió a enterorrafia primaria (63.2 pòr ciento). Los hallazgos intraoperatorios más frecuentes resultaron ser: hemoperitoneo (39,2 por ciento) y peritonitis (15.2 por ciento). Morbilidad 29.1 por ciento, la más frecuente fue causada por la colección residual (8.9 por ciento) seguida de infección de herida operatoria (5 por ciento). El tiempo promedio de hospitalización fue de 6 días. A pesar del avance tecnológico, la herida penetrante abdominal sigue siendo un cuadro en el que el cirujano debe indicar un manejo quirúrgico basado, casi exclusivamenete, en su experiencia y buen juicio clínico.

Subxiphoid pericardial window in stable cardiac proximity injuries

The use of the subxiphoid pericardial window (SPW) in evaluating stable patients with cardiac proximity injuries is presented in a short case series. There were 11 patients with four positive and seven negative SPW. There was one false positive and no false negatives. Review of the literature on the use of the SPW as a diagnostic tool in evaluating cardiac proximity injuries shows the SPW to be a rapid and reliable method of detecting occult cardiac injuries, and is especially useful in areas where emergency echocardiography is not available

Management of liver injuries in Paholpolpayuhasena Hospital.

This retrospective study of 64 patients undergoing surgery was conducted at Paholpolpayuhasena Hospital from September 1992 to August 2002. Fifty-two patients (81.2%) were male and 12 patients (18.8%) were female. The patients' age range was between 10 to 79 years, and 24 patients (37.5%) were in the age group of 20-29 years. Forty-one patients (64.1%) had blunt abdominal trauma, the most common cause of which was traffic accidents, and the most common associated injury of which was splenic injuries. Twenty-three patients (35.9%) had penetrating abdominal trauma, the most common cause of which was stab wounds, and the most common associated injury of which was ileum injuries. The classification of liver injuries was found to be grade II injury in most patients (20 patients, 31.2%). Hepatorrhaphy with suture ligature of the bleeding points and disrupted bile ducts with drainage was the surgical treatment performed in almost all patients (20 patients, 31.2%). The results of treatment were recovery in 49 patients (76.6%), mortality in 15 patients (23.4%), and complications in 20 patients (31.3%). Most of the therapeutic outcomes were accounted for by patients with blunt abdominal trauma.

Intercostodiaphragmatic hernia secondary to a bull gore injury: a delayed detection.

We report a case of a 45-year-old male presenting with asymptomatic right lower chest mass following a forgotten penetrating trauma. This case highlights a rare; delayed complication of lower chest penetrating injuries by the bull gore, involving the diaphragm. Intercostodiaphragmatic hernia should be kept as a differential diagnosis of slowly growing lower chest wall asymptomatic masses with forgotten injuries in the past.

Traumatic diaphragmatic injuries

Traumatic diaphragmatic injury is a potentially serious complication, which can be overlooked at the time of presentation. 1 present 15 cases of blunt [14] and penetrating [one] injuries of the diaphragm encountered during surgical practice in 4 years time. Most of the injuries were on the left side [12 cases], 2 on the right side and only one case with bilateral injury. Rupture was correctly diagnosed or suspected in 12 cases. High suspicion index is required to diagnose such cases. 1 failed to diagnose 3 cases. The diaphragmatic injuries are almost always associated with other injuries and prognosis depends upon presence of such associated injuries. Chest X-rays proved to be of great value in diagnosing diaphragmatic injuries and other diagnostic aids are occasionally needed. All cases treated surgically using polypropylene mesh and very good results obtained except for little morbidities unrelated to the diaphragmatic injury itself and one recorded mortality due to severe head injury

Uso de la escala revisada de trauma (RTS) como valor predictivo de lesión diafragmática en pacientes con trauma toracoabdominal penetrante / Trauma score revised (RTS) as predictive value of diaphragmatic lesion in patients with penetrating toracoabdominal trauma

El trauma representa actualmente una de las principales causas de muerte en la población general. Los pacientes víctimas de trauma requieren de un diagnóstico y tratamiento aplicados de manera rápida y eficaz, ya que son enfermos potencialmente graves. El diagnóstico en pacientes con trauma toracoabdominal penetrante representa un punto difícil, ya que son pocos los datos clínicos que nos dan la certeza de lesión diafragmática. Aunado a esto, no existen estudios paraclínicos con sensibilidad y especificidad confiables. Proponemos la aplicación de un índice fisiológico que tenga valor predictivo en este tipo de enfermos. Incluimos 37 pacientes con trauma toracoabdominal penetrante de etiología variada, a los cuales se les realizó exploración física a su ingreso, incluyendo escala revisada de trauma. Treinta y cuatro enfermos desarrollaron síntomas y/o signos que indicaron exploración quirúrgica; de ellos, 16.2 por ciento fueron laparotomías blancas. Se correlacionaron los datos de la escala revisada de trauma (RTS) con los hallazgos operatorios, con el fin de prever estos casos de cirugía innecesaria.

Heridas del recto extraperitoneal / Extraperitoneal rectum wounds

Antecedentes: Las heridas del recto extraperitoneal están asociadas con un alto potencial de complicaciones sépticas si no son reconocidas precozmente y tratadas de manera adecuada. Objetivos: Evaluar nuestra experiencia en el tratamiento de este tipo de lesiones. Analizar protocolos de tratamiento. Lugar de aplicación: Servicio de Coloproctología del Complejo Médico Churruca-Visca. Diseño: Estudio retrospectivo. Material y Métodos: Se trataron 46 pacientes con heridas de recto extraperitoneal, en el Servicio de Coloproctología del Hospital Churruca-Visca durante el período comprendido entre Junio de 1987 y Febrero de 2000. Se analizan los diferentes mecanismos de lesión, las variantes terapéuticas utilizadas y su evolución clínica. Resultados: La edad promedio de los pacientes tratados fue de 34.23 años, correspondiendo el 91 por ciento de los casos al sexo masculino. En el 93.47 por ciento de los pacientes (43 casos) el tacto rectal y la RSC fueron efectivos para diagnosticar la lesión. Los agentes traumáticos fueron el 63 por ciento (29 casos) herida de bala, el 24 por ciento (11 casos) heridas punzantes y el 13 por ciento (6 casos) traumatismos cerrados. Fueron tratados mediante colostomía sigmoidea a cabos divorciados, drenaje de los espacios isquiorrectales y pelvisubperitoneales y lavado distal del recto, el 86 por ciento de los heridos de bala, el 81 por ciento de las heridas punzantes y el 100 por ciento de los traumatismos cerrados. En los casos en donde no se realizó drenaje de los espacios o la colostomía se efectuó en continuidad, se hallaron graves complicaciones con cuadros sépticos que obligaron a sucesivas reintervenciones. La morbilidad global fue del 26 por ciento y la mortalidad del 4.3 por ciento (2/46). Conclusiones: Se aconseja el uso de la colostomía cercana al foco en la totalidad de los casos (de preferencia a cabos divorciados). El drenaje de ambos espacios isquiorrectales y pelvisubperitoneales se realiza de manera sistemática. El lavado del recto distal es aconsejable para disminuir la carga fecal del intestino desfuncionalizado. La sutura de la herida rectal es un gesto no imprescindible.

Penetrating Injury to the great vessels: case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.