An Individualized Low-Pneumoperitoneum-Pressure Strategy May Prevent a Reduction in Liver Perfusion during Colorectal Laparoscopic Surgery.

High intra-abdominal pressure (IAP) during laparoscopic surgery is associated with reduced splanchnic blood flow. It is uncertain whether a low IAP prevents this reduction. We assessed the effect of an individualized low-pneumoperitoneum-pressure strategy on liver perfusion. This was a single-center substudy of the multicenter 'Individualized Pneumoperitoneum Pressure in Colorectal Laparoscopic Surgery versus Standard Therapy II study' (IPPCollapse-II), a randomized clinical trial in which patients received an individualized low-pneumoperitoneum strategy (IPP) or a standard pneumoperitoneum strategy (SPP). Liver perfusion was indirectly assessed by the indocyanine green plasma disappearance rate (ICG-PDR) and the secondary endpoint was ICG retention rate after 15 min (R15) using pulse spectrophotometry. Multivariable beta regression was used to assess the association between group assignment and ICG-PDR and ICG-R15. All 29 patients from the participating center were included. Median IAP was 8 (25th-75th percentile: 8-10) versus 12 (12,12) mmHg, in IPP and SPP patients, respectively (p < 0.001). ICG-PDR was higher (OR 1.42, 95%-CI 1.10-1.82; p = 0.006) and PDR-R15 was lower in IPP patients compared with SPP patients (OR 0.46, 95%-CI 0.29-0.73; p = 0.001). During laparoscopic colorectal surgery, an individualized low pneumoperitoneum may prevent a reduction in liver perfusion.

Diffuse cavernous hemangioma of the rectum.

Diffuse cavernous hemangioma (DCH) is a rare benign vascular lesion. The rectosigmoid colon is the most common site of this disease. It affects mainly young adults. The most frequent symptom is chronic rectal bleeding which is painless, often begins in the infancy and sometimes is uncontrollable. Endoscopy is the diagnose method of choice and complete surgical excision with sphincter-saving procedure is the primary mode of treatment. A high index of suspicion and a correct diagnose is necessary. We present a 34-year-old male with a DCH of the rectum and anus who required an APR because of affection of dentate line.

El hemangioma cavernoso difuso (HCD) es un tumor vascular benigno raro. Su localización más habitual es el rectosigma. Se presenta en adultos jóvenes como rectorragia indolora y recurrente, que suele aparecer en la infancia y puede llegar a ser incontrolable. La endoscopia digestiva es el método diagnostico de elección. El único tratamiento eficaz consiste en la resección completa siendo deseable la realización de una técnica con conservación esfinteriana. Un alto índice de sospecha y un correcto diagnóstico son necesarios. Presentamos el caso de un varón de 34 años con un HCD del anorecto que requirió una resección abdominoperineal.

Aneurisma esplénico asociado a una fístula arteriovenosa hiliar / Splenic Aneurism Associated with a Hilar Arteriovenous Fistula

Los aneurismas esplénicos son los aneurismas viscerales más frecuentes. Habitualmente son asintomáticos y se diagnostican de forma incidental al realizar estudios de imagen por otra patología. Su importancia clínica radica en la posibilidad de ruptura y la elevada mortalidad que ello implica. La mayoría de los aneurismas son únicos y de pequeño tamaño. La presencia de una fístula arteriovenosa hiliar o intraesplénica asociada es excepcional y suele estar en relación con traumatismos, cirugías previas, infecciones o ser de origen congénito. Presentamos el caso de un aneurisma intraesplénico asociado a una fístula arteriovenosa en el hilio, tratado satisfactoriamente mediante abordaje laparoscópico (AU)

Splenic aneurisms are the most frequent visceral aneurisms. These aneurisms are usually asymptomatic and are diagnosed incidentally by imaging studies performed for other diseases. The clinical importance of these entities lies in the possibility of rupture, leading to high mortality. Most aneurisms are single and small-sized. The presence of an associated hilar or intrasplenic arteriovenous fistula is exceptional and is usually related to trauma, prior surgery, or infections; a congenital origin may also be involved. We present a case of intrasplenic aneurism associated with a hilar arteriovenous fistula, which was satisfactorily treated through the laparoscopic approach (AU)

[Splenic aneurism associated with a hilar arteriovenous fistula]. / Aneurisma esplénico asociado a una fístula arteriovenosa hiliar.

Splenic aneurisms are the most frequent visceral aneurisms. These aneurisms are usually asymptomatic and are diagnosed incidentally by imaging studies performed for other diseases. The clinical importance of these entities lies in the possibility of rupture, leading to high mortality. Most aneurisms are single and small-sized. The presence of an associated hilar or intrasplenic arteriovenous fistula is exceptional and is usually related to trauma, prior surgery, or infections; a congenital origin may also be involved. We present a case of intrasplenic aneurism associated with a hilar arteriovenous fistula, which was satisfactorily treated through the laparoscopic approach.

[Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center]. / Fracturas de pelvis graves, lesiones asociadas e inestabilidad hemodinámica: incidencia, manejo y pronóstico en nuestro medio.

INTRODUCTION: The aim of this study was to review the incidence, treatment and outcome of severe pelvic fractures, as well as associated injuries, in our center. PATIENTS AND METHOD: We performed a retrospective study of patients included in our trauma registry between June 1993 and January 2005. Pelvic fractures were classified according to the system proposed by Tile. Clinical and demographic data such as age, gender, mechanism of injury, transfer time, hemodynamic status, and trauma scores were compared and analyzed statistically. Shock was defined as a systolic blood pressure of < or = 90 mmHg during the primary assessment. Mortality and associated risk factors were analyzed, with emphasis on patients in shock on admission. RESULTS: Of 1274 patients with severe trauma admitted during the study period, 192 (15%) had pelvic fracture. Only 6.7% were isolated fractures and 6% were open fractures. Twenty percent of the patients were in shock on admission. The mean Injury Severity Score of the series was 28.5 +/- 14 and that of patients in shock was 38 +/- 16. The most frequently associated injuries were thoracic (70%), abdominal (55%), long bone fractures (52%), and head injuries (40%). Twenty-three percent of the patients had retroperitoneal hematoma. Arteriograms were performed in 16 patients, with four embolizations. Eight patients underwent external orthopedic fixation, and none posterior orthopedic fixation. Five patients underwent pelvic packing and two patients underwent ligation of hypogastric arteries. Overall mortality was 30% and mortality in patients in shock was 61%. Predictors of mortality were shock on admission, a Glasgow Coma Scale score of < or = 8, ISS > 25 and age > 55 years. CONCLUSIONS: Patients in shock with pelvic fractures have a poor prognosis in our center, frequently related to the severity of associated injuries, the relative rarity of these fractures, and the lack of a clearly defined management protocol. The main cause of death was massive hemorrhage.

Fracturas de pelvis graves, lesiones asociadas e inestabilidad hemodinámica: incidencia, manejo y pronóstico en nuestro medio / Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center

Introducción. El objetivo de esta revisión ha sido conocer la incidencia, lesiones asociadas, tratamiento y resultados obtenidos en el manejo de los pacientes con fracturas graves de pelvis en nuestro centro. Pacientes y método. Estudio retrospectivo de los pacientes incluidos en nuestro registro de traumatizados graves entre junio de 1993 y enero de 2005. La clasificación de las fracturas pelvianas se ha realizado con los criterios de Tile. Se comparan y analizan estadísticamente aspectos demográficos y clínicos, incluidos la edad, el sexo, el mecanismo lesivo, tiempo de traslado, la situación hemodinámica al ingreso y las escalas de gravedad. Se ha definido el estado de shock como una presión arterial sistólica ≤ 90 mmHg durante la revisión primaria. Se analizan la mortalidad y los factores de riesgo asociados, con especial énfasis en el grupo de pacientes en shock. Resultados. De los 1.274 politraumatizados graves atendidos en el período de estudio, 192 (15%) presentaban fractura pelviana. Muy pocas fracturas se han presentado como lesiones aisladas (6,7%), y el porcentaje de fracturas abiertas ha sido del 6%. El 20% de los pacientes presentaba shock al ingreso. El Injury Severity Score (ISS) medio de la serie fue de 28,5 ± 14, y el de los pacientes en shock fue de 38 ± 16. Las lesiones asociadas más frecuentes fueron las torácicas (70%), seguidas por las abdominales (55%), fracturas de huesos largos (52%) y craneoencefálicas (40%). El 23% de los pacientes presentaba hematoma retroperitoneal. Se realizaron 16 arteriografías y 4 embolizaciones pelvianas. Se colocaron 8 fijadores externos anteriores y ninguno posterior. Se realizaron 5 taponamientos pelvianos y 2 ligaduras de arterias hipogástricas. La mortalidad general fue del 30%, y del 61% en los pacientes en shock al ingreso. El shock a la llegada, una escala de coma de Glasgow ≤ 8, un ISS > 25 y la edad > 55 años se correlacionaron con la mortalidad. Conclusiones. El pronóstico de los pacientes en shock y con fracturas de pelvis graves en nuestro medio es sombrío y, con frecuencia, está condicionado por la gravedad de las lesiones asociadas, la relativa escasa incidencia de estas fracturas y la heterogeneidad de criterios de manejo de los equipos de guardia. La hemorragia masiva incontrolada ha sido la causa principal de muerte (AU)

Introduction. The aim of this study was to review the incidence, treatment and outcome of severe pelvic fractures, as well as associated injuries, in our center. Patients and method. We performed a retrospective study of patients included in our trauma registry between June 1993 and January 2005. Pelvic fractures were classified according to the system proposed by Tile. Clinical and demographic data such as age, gender, mechanism of injury, transfer time, hemodynamic status, and trauma scores were compared and analyzed statistically. Shock was defined as a systolic blood pressure of ≤ 90 mmHg during the primary assessment. Mortality and associated risk factors were analyzed, with emphasis on patients in shock on admission. Results. Of 1274 patients with severe trauma admitted during the study period, 192 (15%) had pelvic fracture. Only 6.7% were isolated fractures and 6% were open fractures. Twenty percent of the patients were in shock on admission. The mean Injury Severity Score of the series was 28.5 ± 14 and that of patients in shock was 38 ± 16. The most frequently associated injuries were thoracic (70%), abdominal (55%), long bone fractures (52%), and head injuries (40%). Twenty-three percent of the patients had retroperitoneal hematoma. Arteriograms were performed in 16 patients, with four embolizations. Eight patients underwent external orthopedic fixation, and none posterior orthopedic fixation. Five patients underwent pelvic packing and two patients underwent ligation of hypogastric arteries. Overall mortality was 30% and mortality in patients in shock was 61%. Predictors of mortality were shock on admission, a Glasgow Coma Scale score of ≤ 8, ISS > 25 and age > 55 years. Conclusions. Patients in shock with pelvic fractures have a poor prognosis in our center, frequently related to the severity of associated injuries, the relative rarity of these fractures, and the lack of a clearly defined management protocol. The main cause of death was massive hemorrhage (AU)