Is aortic occlusion advisable in the management of massive hemorrhage? Experimental study in dogs.

Occlusion of the thoracic aorta is meant to improve cerebral and cardiac perfusion in the moribund, exsanguinating trauma patient. Yet clinical and experimental experience shows no evident benefit from this critical maneuver, and hind limb paralysis (HLP) is a feared complication. Our study is intended to verify whether aortic occlusion can decrease further blood loss and therefore be useful during treatment of hemorrhagic shock. Four groups of 10 dogs were submitted to hemorrhagic shock and treated with blood (40 mL/kg) and saline (35 mL/kg). Group I was then submitted to intermittent intra-aortic occlusion (IIAO), Groups II and III to IIAO and to a second bleeding (rebleeding), and Group IV to rebleeding only, without IIAO. All dogs received volume replacement during this rebleeding phase and were kept alive for 8 days. Five dogs died and seven had HLP in the three groups submitted to IIAO. Death and HLP occurred even in the dogs of Group I, which were not submitted to a second bleeding. IIAO reduced blood loss from 139 mL/kg to 48 mL/kg. There were no complications or deaths among the 10 dogs in Group IV. Although efficient in reducing blood loss, IIAO was associated with a 16% mortality and 23% of HLP, whereas volume replacement alone was tolerated without complications or death. We conclude that IIAO is dangerous while treating severe hemorrhagic shock even after volume replacement and hemodynamic stabilization.

[Traumatic rupture of duodenal diverticulum. Report of a case and literature review]. / Ruptura traumática de divertículo duodenal. Relato de um caso e revisão da literatura.

Duodenal diverticulum is a common anatomic abnormality. Its inflammatory perforation is a rare complication, with less than 100 cases reported in the available literature. Traumatic perforation is exceedingly rare (only 3 cases reported). In this report one more case of traumatic perforation is presented, and the literature is reviewed focusing on the pathogenic, diagnostic and therapeutic aspects of this severe disease.

[Traumatic injuries of the pancreas: report of 65 cases]. / Lesões traumáticas do pâncreas: análise de 65 casos.

With the aim of aiding the accurate diagnosis and treatment of patients with pancreatic injuries, we reviewed the medical records of sixty-five patients, treated for traumatic pancreatic lesions at the Department of Surgery of the University of São Paulo in the 5-year period from 1989 through 1993. Records, including operative and pathology reports, were reviewed and the location of the pancreatic injury, associated intra-abdominal injuries, type of injury, trauma scores, treatment, complications and mortality rates recorded. There were 58 male and seven female patients with a mean age of 28.3 years (range, 2-77 years). Of the 65 pancreatic injuries, 45 (69.2%) were caused by penetrating wounds and twenty by blunt trauma. The most frequent site of lesion was the head of the pancreas (38.5%). Associated injuries were found in all but five of the patients. In the 65 patients, 170 intra-abdominal injuries were found (2.6 per patient). Twenty-eight of the 65 patients (43.1%) had liver lacerations. Lacerations of major abdominal vessels (27 patients), gastric lacerations (25 patients) and colorectal lacerations (17 patients) were the next most frequent injuries. Fifteen out of twenty patients died within two days after the accident from severe concomitant injuries. Simple drainage was performed in 33 patients, distal pancreatectomy in 17 and duodenopancreatectomy in six patients. Pancreas-related complications occurred in 20 (30.7%) out of 57 patients who survived the initial operation. We concluded that the type of repair employed in our series was related to the class of injury and clinical conditions (based on trauma scores). Therefore, whenever possible, conservative management (no pancreatic resection) was employed in patients that sustained class I and II injuries and pancreatic resection in class III and IV injuries.

[A fatal case of lower gastrointestinal hemorrhage: report of case and review of the literature]. / Evolução fatal de hemorragia digestiva baixa: relato de caso e revisão da literatura.

Gastrointestinal hemorrhage continues to be a major medical problem. Even with improvements in both diagnostic and therapeutic, a significant number of patients still require surgical intervention for control of hemorrhage. When the source of persistent lower gastrointestinal hemorrhage is unknown, subtotal colectomy is a conceptually rational management choice. The authors present a case of massive lower gastrointestinal hemorrhage with unusual fatal outcome. A review of literature of this condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.

An unusual case of four iliac veins injured by gunshot: case report and review of the literature.

Multiple injuries of iliac veins are uncommon and frequently fatal. An unusual case in which there were injuries of the four iliac veins by gunshot is described. Prompt control of hemorrhage is required. Because our patient was in unstable condition, ligation of the four iliac veins was performed and the abdomen was packed. After a complicated course, the patient was discharged after 40 days in good condition. Although venous repair is often recommended, ligation in extensive injuries may be necessary, and is usually well tolerated in young, previously healthy individuals like our patient.

[Risk factors in emergency surgery relaparotomy]. / Fatores de risco em relaparotomia na cirurgia de urgência.

Reintervention in abdominal surgery involves the difficulty of precise indication and the limitations of surgical technics during the operation. It may bring to evidence professional errors. It presents a very high morbimortality index. In order to establish risk factors and death rate, we comparatively analysed the initial diagnoses, the number, the cause and the time of relaparotomy, the existence of associated diseases, the age and the illness severity, using APACHE-II after the first surgical intervention. During a two years period starting 1990 we retrospectively analysed charts of 40 patients submitted to relaparotomy in the Emergency Service of Hospital das Clínicas of Medicine University of São Paulo.

[Postsplenectomy gastric fistula: report of a case]. / Fístula gástrica pós-esplenectomia relato de caso.

Gastric perforation following splenectomy is a rare complication occurring in less than 1% of patients and it is mainly associated with iatrogenic injury to the greater curvature of the stomach. The authors report a case of gastric fistula in a patient who underwent splenectomy for blunt abdominal trauma and discuss the main etiopathogenic and diagnostic aspects.

[Gastric wounds: study of 85 patients]. / Ferimentos gástricos: estudo de 85 casos.

During January 1987 and December 1990 we studied 85 patients (75 males), the age varying between 6 and 47 years (mean 27.6) sustaining penetrating (81 patients) and blunt (4 patients) gastric wounds. The mortality rate was 17.6% (15 patients) with four deaths occurring during the surgical procedure as consequence of critical associated injuries. Only one death happened as consequence of gastric wound; 6 patients died during the first 24 hours of hospitalization because of irreversible shock, 9 deaths came about after the first day of hospitalization (4 sepsis, 3 respiratory failure, 2 head trauma). The morbidity rate among the 81 patients that survived after surgical treatment was 39.5% (32 patients). The main postoperative gastric complication was vomiting in 10 patients (5 presenting vagus nerve injury and 5 sustaining pancreatic and/or another hollow viscus wounds) one patient presented with gastric suture dehiscence. Among the 12 patients sustaining vagus nerve injury the presence of gastric complication was higher in the group that was not submitted to pyloroplasty (6 patients). Analysing the patients presenting gastric and pancreatic injuries we verified that morbidity rate was statistically significantly higher in this group (69.2%) than in overall morbidity (39.5%).

[Simultaneous injury of 4 iliac veins by firearm: report of a case and review of the literature]. / Lesão simultânea das quatro veias ilíacas por arma de fogo: relato de caso e revisão bibliográfica.

Iliac vessel injuries constitute approximately 10 percent of all vascular traumatic lesions. The high mortality rate is due to the massive exsanguination and the high frequency of associated injuries. Iliac vein injury occurs either isolated or in association with the arterial lesion. Multiple injuries of iliac veins are uncommon and frequently fatal. An unusual case, in which there were injuries of the four iliac veins by gunshot is described. A review of literature of this condition and a discussion about the diagnosis, treatment and factors affecting mortality rate is presented. No other such case has been found reported.

[Traumatic rupture of the diaphragm: study of 35 cases]. / Ruptura diafragmática traumática: estudo de 35 casos.

A retrospective review of 35 patients with diaphragmatic injury attended at the Emergency Service of the Hospital das Clínicas, University São Paulo is analysed. Diagnosis was made through chest roentgenogram (48.5%), peritoneal lavage (37%) and contrast studies (14.5%). The most common extra-abdominal lesion were due to head, pelvic and thoracic trauma. Thirty-one patients sustained injuries to the left-side and four to the right. Associated intra-abdominal injury occurred in 89% of them. Retroperitoneal haematoma, spleen and liver injury were the most frequent lesions. All cases were treated by laparotomy, pleural space irrigation through the diaphragmatic lesion, thoracic drainage and suture of the injury. The morbidity rate was 40% and deaths occurred in 22.8%. Based upon these data, we concluded: the mechanism of trauma, chest RX findings and pelvic fracture are important clues for early recognition; irrigation of pleural space seems to be important in order to prevent empyema. Despite of this, the mortality remains high.

[Traumatic right diaphragmatic hernia: report of a case and review of the diagnostic methods]. / Hernia diafragmática traumática direita: relato de caso e revisão demétodos diagnósticos.

Rupture of the right hemidiaphragm from blunt trauma is uncommon. Better management and more rapid transportation of victims has increased the frequency with which patients sustaining this injury are arriving at the emergency room alive. A case of right-sided diaphragmatic hernia from blunt trauma in a 36-year-old man is reported. Diagnosis was established by chest x-ray, CT scan and digital exploration after unsuccessful thoracoscopy. The methods used for diagnosis of this condition are analysed.

[Tissue necrosis: a side effect of sodium diclofenac: report of cases and discussion of the physiopathology]. / Necrose tecidual: efeito colateral do diclofenaco de sódio, relato de casos e discussão da fisiopatologia.

Diclofenac sodium is a non-steroidal anti-inflammatory widely used drug both in the treatment of the rheumatic diseases and as analgesic. The fact that is a potent analgesic spread its use to almost all fields in medicine, increasing the reports of adverse effects associated with it. The main complications reported are gastrointestinal, dermatological and of the central nervous system. The authors present seven cases that developed tissue necrosis as a result of the intramuscular injection of diclofenac sodium. Because of the low incidence or this adverse effect, a review is carried out and the physiopathologic mechanisms likely to be involved are discussed. Our aim is to warn against the indiscriminate intramuscular use of this drug.

[Traumatic rectal injuries]. / Ferimentos traumáticos de reto.

The authors review the cases of traumatic rectal injuries admitted to the Emergency Service of the "Hospital das Clínicas", University of São Paulo Medical School, during the period of July 1981 to July 1988. Forty-five patients (62.5%) had their injuries due to gunshot, 14 (19.4%) due to foreign bodies on the rectum, 10 (13.8%) due to blunt trauma and 3 (4.1%) due to stab wounds. The intraperitoneal rectum was injured in 32 patients (44.4%) and extraperitoneal portion of the rectum in 40 patients (55.5%). On the intraperitoneal injuries the management adopted were simple suture (14 patients), associated with a colostomy (17 patients) and in one patient the Hartmann procedure was adopted. On the extraperitoneal wounds the management adopted were rectal repair (when feasible), colostomy, distal washout and drainage. The complications rate was 27.8%, and from them, the majority (70%) were related to infectious nature. Seven patients died (9.7%), four of them as a consequence of sepsis. The morbidity and mortality of the rectal injuries were closed related to infectious complications as a consequence of late diagnosis. For this reason, the authors consider that all efforts should be employed to establish the prompt diagnosis.

[Acute abdomen in elderly patients]. / Abdome agudo em paciente geriátrico.

Seventy nine elderly patients with acute abdominal conditions were operated on in the Emergency Service of the Hospital das Clinicas of the University of São Paulo from 1981 to 1985. Total mortality rate was 58.23%. In patients with acute vascular abdominal conditions it was 100%, in inflammatory conditions 55.17% and in intestinal obstruction 47.83%. The lowest mortality was observed in traumatic conditions (27.27%). Procrastination of operations was followed by higher mortality. In operations lasting more than three hours the mortality was significantly higher than in those lasting less than three hours. Associated diseases as well as reoperations increased the postoperative mortality.

Endoscopic percutaneous gastrostomy without laparotomy.

Observation and manipulation through the endofiberscope, have resulted in a new method of establishing gastrostomy without laparotomy. Subsequent to experimental studies with dogs, the new method was employed to substitute nasogastric tube in patients. In this new procedure, endoscopic application permits the placing of stitches in close contact with the abdominal and gastric walls. The fact that no complications were observed in the patients submitted to operative treatment, is largely attributed to this type of suture. From the results obtained it would seem that this procedure can be routinely employed instead of gastrostomy with laparotomy, since it offers the advantage of being a simpler method and is more likely to be associated with a lower rate of complications.