[Damage control surgery in abdominal trauma].

The damage control laparotomy is an advancement in the management of massively injured trauma patients. Massive liver injuries, pelvic trauma and some retroperitoneal injuries are some of the indications for this approach. The damage control laparotomy is the phased approach to severe abdominal injury that might best be described with the acronym STIR (Staged Trauma Injury Repair). The initial procedure requires rapid abdominal exploration with hemorrhage and contamination control, using suture repair combined with abdominal packing. Temporary abdominal wall closure without tension is recommended. After abrevated initial surgical procedure, the patient is transferred to the intensive care unit where continued resuscitation is performed. Careful replacement of blood and blood products along with correction of hypothermia, acidosis and optimalization of oxygen transport represents a critical phase in this management approach. Once the coagulation profile has normalized, planned re-intervention, with repeat abdominal exploration to remove the packs and perform definitive surgical repair and reconstruction takes place. When applied judiciously, the damage control laparotomy with the staged abdominal repair and reconstruction for severe trauma is associated with an improved outcome in the selected group of patients.

[Postoperative use of nonsteroidal anti-inflammatory agents in orthopedic surgery].

Nonsteroidal antiinflamatory drugs (NSAIDs) lead to satisfactory acute and chronic pain relief. Besides that, they exert potent antiinflamatory effect. Their analgesic potency is dose related and limited. Orthopedic patients are often on these medications preoperatively and experience opioid-sparing effect in the postoperative period. Chronic NSAIDs use is related to higher rate of sistemic adverse effects, but even short time exposure in the postoperative period is not risk-free. Although Coxibs reduce GIT bleeding incidence due to prolonged use of NSAIDs, there has to be judicious decision considering their cardiovascular adverse effects. There is evidence that NSAIDs producing moderate, dose-dependent increased bleeding time within normal values. High risk of bleeding have patients with established coagulopathy, alcohol abuse and on anticoagulant treatment. There is no strong evidence on influence of NSAIDs on bone growth. Nevertheless, there is evidence that NSAIDs do prevent heterotropic ossification. Prostaglandins are vital contributors for maintainig tissue homeostasis and NSAIDs use can lead to many unwanted effects. Those adverse effect are more common with prolonged exposure, are dose-related and risks have to be carefully and individually assesed in the postoperative pain management.

[Risk factors for bleeding from stress ulcer in severely injured and critically ill persons].

Bleeding stress ulcus is a mucosal stress induced lesion which appears as a result of mucosal damage in severely injured and critically ill persons. Prophylaxis treatment has dramatically reduced the incidence of bleeding in Intensive care units. We conducted a prospective study for the five years period. Of 954 patients (196 with acute necrotizing pancreatitis and 758 with severe injuries), 84 (8.5%) has clinically important bleeding. About 80% of these patients had more than one independent risk for acute bleeding from gastrointestinal tract. Prophylaxis treatment reduced bleeding in 90% risk patients (according Zinner score). Despite of prophylaxis, 13 patients required surgery. Overall mortality was 29 (34%) of 84 patients, including seven of 13 who required surgery. Sepsis and respiratory failure were identified as strong risk factors for bleeding in our group. The choice of the best prophylactic agens still remains the question.

[Total gastrectomy in the surgical treatment of acute massive hemorrhage caused by Dieulafoy lesion of the gastric fundus].

GI bleeding caused by Dieulafoy lesion in the gastric fundus: a case report Dieulafoy lesion is a rare cause of massive gastrointestinal (GI) hemorrhage that can be fatal. It arises from an abnormally large eroded submucosal artery and in more than 75% of cases the lesion is mostly found within 6 cm of the cardia. The severity of bleeding and the site of the lesion render the diagnosis sometimes difficult, more than one endoscopic exam is often required. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. We report a case of an 42-year-old man presented with upper GI hemorrhage. Repeated upper GI endoscopies revealed a missed diagnosis of subcardial gastric ulcer and Mallory-Weis lesion. Following conservative treatment, the frequency and amount of haemorrhage decreased and totally stop. 48 hours after admission patient developed sudden massive upper GI bleeding and underwent emergency total gastrectomy. The diagnosis of Dieulafoy lesion was made histologically. The patient recovered uneventfully and discharged on the postoperative day 11th. Therefore, Dieulafoy disease represent a diagnostic and therapeutic challenge. Advances in endoscopic technique have greatly assisted in earlier diagnosis and added options to the treatment regimen for this lesion. The relationship of this anomaly to possible exsanguination makes it essential that both endosopical and surgical approach play an important role in the management of this pathology.