ABSTRACT
RESUMEN Antecedentes: la fístula biliopleural (FBP) es una complicación poco común del traumatismo torácico-abdominal que se confirma demostrando la presencia de bilis en el líquido pleural. Objetivo: analizar el manejo y tratamiento realizado de las fístulas biliopleurales producto del traumatismo torácico-abdominal abierto y los resultados, comparar con la literatura y proponer algoritmo de tratamiento. Material y métodos: trabajo retrospectivo y descriptivo mediante la revisión de 5688 historias clínicas de pacientes, de los cuales 614 tenían compromiso de la región torácica abdominal, en el Hospital José María Cullen, Santa Fe, Argentina, Centro de Trauma Nivel 1, en el período comprendido entre enero de 2010 y enero de 2016. Se analizaron los datos demográficos, cinemática del traumatismo, diagnóstico, tratamiento y evolución. Resultados: se encontraron 7 casos de FBP. Todos fueron varones jóvenes con traumatismo abierto. Se realizó drenaje pleural como tratamiento inicial en 4 casos; en 2, drenaje pleural y laparotomía exploradora y en 1 toracotomía de urgencia. Dos casos resolvieron solo con el drenaje pleural. En 5 casos se efectuó drenaje de la vía biliar mediante colangiopancreatografía retrógrada endoscópica con esfinterotomía. En 2 de ellos, además, se colocó un stent biliar. Dos de los 5 necesitaron drenaje percutáneo. Por último, 2 casos requirieron toracotomía y 1 de estos, pleurostomía abierta. Todos resolvieron la afección con morbilidad aceptable, sin mortalidad. Conclusión: en la práctica quirúrgica actual, la amplia disponibilidad de endoscopia intervencionista ha mejorado el enfoque invasivo mínimo para el manejo de las fístulas biliopleurales. Se reserva el manejo quirúrgico para aquellas que no responden al tratamiento invasivo mínimo o para las fístulas complicadas, o para ambas.
ABSTRACT Background: Pleurobiliary fistula is a rare complication of thoraco-abdominal trauma that is confirmed by the presence of bilirubin in pleural fluid. Objective: The aim of this study is to analyze the management and treatment performed to patients with pleurobiliary fistula due to penetrating thoracoabdominal injury and their results, compare them with the published literature, and propose a treatment algorithm. Material and methods: For this descriptive and retrospective study, we reviewed 5688 medical records of patients admitted to Hospital José María Cullen, Santa Fe, Argentina, Centro de Trauma Nivel 1 between January 2010 and January 2016; 614 had involvement of the thoracic and abdominal region. The demographic data, kinematics of trauma, diagnosis, treatment and patient progress were analyzed. Results: Seven cases of pleurobiliary fistula were found. All the patients were men with penetrating trauma. Pleural drainage was the initial treatment in 4 cases, 2 patients underwent pleural drainage and exploratory laparotomy and 1 patient underwent urgent thoracotomy. Two cases resolved with pleural drainage alone. Five patients require biliary drainage through endoscopic retrograde cholangiopancreatography with sphincterotomy. Two of these patients also required biliary stenting and 2 also underwent percutaneous drainage. Finally, 2 patients required thoracotomy, 1 of them with open pleurostomy. The fistulae resolved in all the cases with acceptable morbidity. None of them died. Conclusion: In current surgical practice, the wide availability of interventional endoscopy has improved the minimally invasive approach for the management of PBF. Surgical management should be limited to fistulae not responding lo less invasive treatments or to complicated fistulae.
ABSTRACT
ANTECEDENTES: La insuficiencia hepática postresección es una de las principales causas de muerte en el postoperatorio de una hepatectomía mayor. La técnica ALPPS aparece como una estrategia prometedora para evitarla, pero no existen estudios experimentales al respecto. El objetivo del trabajo es desarrollar un modelo experimental de ALPPS en ratas. MÉTODO: Se desarrolló un modelo experimental de ALPPS en 30 ratas Sprague Dawley. Se realizó la ligadura de la rama portal izquierda del lóbulo medio (LM), con lo cual se demarca el sector izquierdo (SILM) y derecho (SDLM); posteriormente se realizó la transección parenquimatosa por la línea isquémica. Se evaluaron el peso del animal, el volumen y peso del LM y de ambos. Sacrificio a los 3, 7 y 14 días (10 por grupo). RESULTADOS: No se presentaron complicaciones hemorrágicas ni ascitis en el postoperatorio. El incremento del volumen del LM fue del 24,1; 86,9 y 120,4% a los 3, 7 y 14 días. El SDLM (no ligado) se incrementó un 34,4; 78,8 y 102,0% a 3, 7 y 14 días. El SILM disminuyó un 42,6; 64,8, y 79,3% en los días 3, 7 y 14. CONCLUSIÓN: La realización del ALPPS fue posible en ratas, logrando los resultados esperados. Futuros estudios son necesarios para compararlo con la técnica de hepatectomía en 2 tiempos
BACKGROUND: Liver failure migth be a cause of death after major hepatectomies. The ALPPS technique appears to be a promising strategy to avoid it, however no experimental studies supporting this procedure have been previously described. The aim was to develop an experimental model of ALPPS in rats. Method. Experimental. A total of 30 Sprague Dawley rats were used. To develop the ALPPS procedure, ligation of the left portal branch of the middle lobe (LM) was performed. This demarcates the left side (SILM) from the right side (SDLM); parenchyma transection was performed following the demarcated line. The animal's weight, volume and weight of both LM were analyzed. Sacrifice at 3, 7 and 14 days after the procedure (10 per group) was performed. RESULTS: No bleeding or ascites were observed during the postoperative period. The LM increased by 24.1, 86.9 and 120.4% at 3, 7 and 14 days. The SDLM increased by 34.4, 78.8 and 102.0% at 3, 7 and 14 days. The SILM decreased 42.6, 64.8, and 79.3% at day 3, 7 and 14 days respectively. CONCLUSION: The ALPPS procedure can be performed in rats, achieving the expected results. Comparison studies to 2 staged hepatectomy will be necessary
Subject(s)
Animals , Male , Rats , Ligation/methods , Ligation/trends , Models, Animal , Hepatectomy/methods , Hepatectomy , Hepatectomy/veterinary , Hepatic Insufficiency/complications , Hepatic Insufficiency/etiology , Microsurgery/methods , Microsurgery/trends , Animal Experimentation , Hepatic Insufficiency/physiopathology , Hepatic Insufficiency/surgery , Microsurgery/standards , Microsurgery , Morphine/therapeutic useABSTRACT
BACKGROUND: Liver failure might be a cause of death after major hepatectomies. The ALPPS technique appears to be a promising strategy to avoid it, however no experimental studies supporting this procedure have been previously described. The aim was to develop an experimental model of ALPPS in rats. METHOD: Experimental. A total of 30 Sprague Dawley rats were used. To develop the ALPPS procedure, ligation of the left portal branch of the middle lobe (LM) was performed. This demarcates the left side (SILM) from the right side (SDLM); parenchyma transection was performed following the demarcated line. The animal's weight, volume and weight of both LM were analyzed. Sacrifice at 3, 7 and 14 days after the procedure (10 per group) was performed. RESULTS: No bleeding or ascites were observed during the postoperative period. The LM increased by 24.1, 86.9 and 120.4% at 3, 7 and 14 days. The SDLM increased by 34.4, 78.8 and 102.0% at 3, 7 and 14 days. The SILM decreased 42.6, 64.8, and 79.3% at day 3, 7 and 14 days respectively. CONCLUSION: The ALPPS procedure can be performed in rats, achieving the expected results. Comparison studies to 2 staged hepatectomy will be necessary.
