Tratamiento del traumatismo cerrado de hígado, indicaciones de cirugía y desenlaces / Surgical treatment of blunt liver trauma, indications for surgery and results

INTRODUCCIÓN: El objetivo final del tratamiento quirúrgico en la obesidad mórbida es el descenso de la morbimortalidad asociada al exceso de peso. En este sentido debemos centrarnos en la enfermedad cardiovascular y el síndrome metabólico, que son las causas principales de mortalidad. El objetivo del estudio es valorar el efecto del bypass gástrico sobre el riesgo cardiovascular estimado en los pacientes sometidos a cirugía bariátrica. MATERIAL Y MÉTODOS: Estudio clínico retrospectivo y observacional desarrollado en 402 pacientes sometidos a bypass gástrico por laparoscopia. La variable principal a estudio es el riesgo cardiovascular estimado, que se mide en el preoperatorio y a los 12 meses. Para el cálculo del riesgo estimado se utiliza la ecuación REGICOR, que se expresa en forma de porcentaje y calcula el riesgo a 10 años de presentar enfermedad cardiovascular. RESULTADOS: En situación basal observamos como media un índice REGICOR de 4,1 ± 3,0. A los 12 meses de la intervención la estimación del riesgo cardiovascular disminuyó significativamente a 2,2 ± 1,6 (p < 0,001). En los sujetos con el diagnóstico de síndrome metabólico según definición del ATP-III, el REGICOR basal fue de 4,8 ± 3,1, mientras que en aquellos sin síndrome fue de 2,2 ± 1,8. A los 12 meses observamos una reducción significativa en ambos grupos (síndrome metabólico y no síndrome) con un REGICOR medio de 2,3 ± 1,6 y 1,6 ± 1,0 respectivamente. CONCLUSIÓN: Los resultados observados en nuestro estudio demuestran los efectos favorables del bypass gástrico sobre los factores de riesgo cardiovascular incluidos en la ecuación REGICOR

INTRODUCTION: The major goal of surgical treatment in morbid obesity is to decrease morbidity and mortality associated with excess weight. In this sense, the main factors of death are cardiovascular disease and metabolic syndrome. The objective of this study is to evaluate the effects of gastric bypass on cardiovascular risk estimation in patients after bariatric surgery. MATERIAL AND METHODS: We retrospectively evaluated pre and postoperative cardiovascular risk estimation of 402 morbidly obese patients who underwent laparoscopic gastric bypass. The major variable studied is the cardiovascular risk estimation that is calculated preoperatively and after 12 months. Cardiovascular risk estimation analysis has been performed with the REGICOR Equation. REGICOR formulation allows calculating a 10-year risk of cardiovascular events adapted to the Spanish population and is expressed in percentages. RESULTS: We reported an overall 4.1 ± 3.0 mean basal REGICOR score. One year after the operation, cardiovascular risk estimation significantly decreased to 2,2 ± 1,6 (P < .001). In patients with metabolic syndrome according to ATP-III criteria, basal REGICOR score was 4.8 ± 3.1 whereas in no metabolic syndrome patients 2.2 ± 1.8. Evaluation 12 months after surgery, determined a significant reduction in both groups (metabolic syndrome and non metabolic syndrome) with a mean REGICOR score of 2.3 ± 1.6 and 1.6 ± 1.0 respectively. CONCLUSION: The results of our study demonstrate favorable effects of gastric bypass on the cardiovascular risk factors included in the REGICOR equation

[Surgical treatment of blunt liver trauma, indications for surgery and results]. / Tratamiento del traumatismo cerrado de hígado, indicaciones de cirugía y desenlaces.

INTRODUCTION: The liver is the most frequently injured organ in blunt abdominal trauma. Patients that are hemodynamically unstable must undergo inmmediate surgical treatment. There are 2 surgical approaches for these patients; Anatomical Liver resection or non-anatomic liver resection. Around 80-90% of patients are candidates for non-operative management. -Several risk factors have been studied to select the patients most suited for a non operative management. MATERIALS AND METHODS: We performed a retrospective study based on a prospective database. We searched for risk factors related to immediate surgical management and failed non-operative management. We also described the surgical procedures that were undertaken in this cohort of patients and their outcomes and complications. RESULTS: During the study period 117 patients presented with blunt liver trauma. 19 patients (16.2%) required a laparotomy during the initial 24h after their admission. There were 11 deaths (58%) amongst these patients. Peri-hepatic packing and suturing were the most common procedures performed. A RTS Score<7.8 (RR: 7.3; IC 95%: 1.8-30.1), and ISS Score >20 (RR 2,5 IC 95%: 1.0-6.7), and associated intra-abdominal injuries (RR: 2.95; IC 95%: 1.25-6.92) were risk factors for immediate surgery. In 98 (83.7%) patients a non-operative management was performed. 7 patients had a failed non-operative management. CONCLUSION: The need for immediate surgical management is related to the presence of associated intra-abdominal injuries, and the ISS and RTS scores. In this series the most frequently performed procedure for blunt liver trauma was peri-hepatic packing.

Best timing for thoracoscopic evacuation of retained post-traumatic hemothorax.

OBJECTIVE: To determine the best timing for thoracoscopic drainage of clotted hemothorax in order to ensure safe and effective results and to identify risk factors associated with drainage failure. MATERIALS AND METHODS: Cohort retrospective study of 139 consecutive patients who underwent thoracoscopic retained hemothorax drainage between April 1997 and May 2005. RESULTS: The procedure was successful in 102 patients (73.4%), in whom complete evacuation was achieved, with no accumulation of fluid in the pleural cavity requiring reintervention. Conversion to thoracotomy was required in 22 patients (15.8%) because of the inability to attain adequate drainage of clots and collections and lung re-expansion. Fifteen patients (10.8%) required reintervention as a result of fluid accumulation in the pleural cavity and lung collapse, and thoracotomy was performed in all those cases. The best results were obtained when thoracoscopic drainage was performed before the fifth day. There were 33 major post-operative complications including 20 cases of empyema of which 10 required thoracotomy, and 13 bronchopleural leaks, four of which required open surgery. There were no fatal outcomes in the study group. CONCLUSIONS: Videothoracoscopy must be considered the procedure of choice for the treatment of retained post-traumatic hemothorax. It is a safe and effective procedure allowing the successful treatment of up to 73.4% of patients. Best results are obtained when drainage is performed within the first five days after trauma.