Risk factors associated with the development of post-traumatic retained hemothorax.

OBJECTIVE: To identify risk factors associated with the development of post-traumatic retained hemothorax in chest trauma patients admitted to Hospital San Vicente de Paul (HUSVP). METHODS: This study was a prospective cohort study that included patients with a diagnosis of chest trauma who required a tube thoracostomy as a therapeutic intervention. The measured outcome was retained hemothorax, defined as the presence of blood in the pleural cavity that could not be drained through the initial tube thoracostomy and appeared radio-opaque or hypodense on X-rays or CT scan. The postoperative follow-up period was 30 days. RESULTS: Six hundred thirty-three thoracostomies were performed over a 28-month period for chest trauma; the incidence of post-traumatic retained hemothorax was 16.7%, and additional complications were seen in 10% of cases. The risk of retained hemothorax was associated with: initial blood drainage (median, 400 ml; p < 0.001), the number of tubes placed (two or more; OR = 5.35, CI 95%: 3.98-7.20), the duration of the tube thoracostomy (median, 5 days; p = 0.01), and the need for mechanical ventilation (RR = 2.5, CI 95%: 1.66-3.75). CONCLUSIONS: The risk of post-traumatic retained hemothorax was associated with four factors. The probability of the outcome could be modified by careful monitoring, management protocols, suction through the tube thoracostomy, and maybe an early intervention, such as thoracoscopy.

Laparoscopic repair for perforated peptic ulcer disease.

BACKGROUND: Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The development of laparoscopic surgery has changed the way to treat such abdominal surgical emergencies. The results of some clinical trials suggest that laparoscopic surgery could be a better strategy than open surgery in the correction of perforated peptic ulcer but the evidence is not strongly in favour or against this intervention. OBJECTIVES: To measure the effect of laparoscopic surgical treatment versus open surgical treatment in patients with a diagnosis of perforated peptic ulcer in relation to abdominal septic complications, surgical wound infection, extra-abdominal complications, hospital length of stay and direct costs. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 2, 2004), PubMed/MEDLINE (1966 to July 2004), EMBASE (1985 to November 2004) and LILACS (1988 to November 2004) as well as reference lists of relevant articles. SELECTION CRITERIA: Randomised clinical trials comparing laparoscopic surgery versus open surgery for the repair of perforated peptic ulcer using any mechanical method of closure (suture, omental patch or fibrin sealant). DATA COLLECTION AND ANALYSIS: Primary outcome measures included proportion of septic and other abdominal complications (surgical site infection, suture leakage, intra-abdominal abscess, postoperative ileus) and extra-abdominal complications (pulmonary). Secondary outcomes included mortality, time to return to normal diet, time of nasogastric aspiration, hospital length of stay and costs. Outcomes were summarized by reporting odds ratios and 95% confidence intervals, using the fixed-effect model. MAIN RESULTS: We included two randomised clinical trials, which were of acceptable quality. We found no statistically significant differences between laparoscopic and open surgery in the proportion of abdominal septic complications (OR 0.66, 95% CI 0.30 to 1.47), pulmonary complications (OR 0.37, 95% CI 0.11 to 1.31) or actual number of septic abdominal complications (OR 0.72, 95% CI 0.33 to 1.58). Heterogeneity was significant only for pulmonary complications. AUTHORS' CONCLUSIONS: This systematic review suggests that a decrease in septic abdominal complications may exist when laparoscopic surgery is used to correct perforated peptic ulcer. However, it is necessary to develop more randomised controlled trials that include a greater number of patients to confirm such an assumption, guaranteeing a long learning curve for participating surgeons. With the information provided by the available clinical trials it could be said that laparoscopic surgery results are not clinically different from those of open surgery.

Value of digital exploration for diagnosing injuries to the left side of the diaphragm caused by stab wounds.

HYPOTHESIS: The digital exploration of stab wounds in the left thoracoabdominal region allows the early diagnosis of diaphragmatic lesions. DESIGN: Diagnostic test study. The digital exploration of the diaphragm was compared with laparotomy (the gold standard) and thoracoscopy. SETTING: The study setting was the Hospital Universitario San Vicente de Paúl (Medellín, Colombia). This is a referral trauma center for the general community. PATIENTS: The study included 82 consecutive patients who were admitted to our institution during a 12-month period with injuries caused by stab wounds to the left thoracoabdominal region and who did not have indications for immediate surgery. Digital exploration of the wound was performed by the attending surgeon in the emergency department. If a lesion of the diaphragm was identified, a laparotomy was performed; if no diaphragmatic lesion was found, a diagnostic left thoracoscopy and/or laparotomy was performed. Results of the laparotomy (n = 63) or thoracoscopy (n = 19) were used as the standard of reference for the determination of sensitivity, specificity, and predictive values of digital exploration. INTERVENTION: The integrity of the diaphragm was determined by digital exploration through the stab wound. MAIN OUTCOME MEASURES: Sensitivity, specificity, predictive value, and likelihood ratio were calculated. RESULTS: For the detection of diaphragmatic lesions, digital exploration demonstrated a sensitivity of 96%, a specificity of 83.3%, a positive predictive value of 91%, and a negative predictive value of 93.7%. CONCLUSION: Digital exploration is a reliable method for the detection of injuries to the left side of the diaphragm caused by stab wounds.

Drenaje del hemotorax coagulado mediante toratoscopia: factores predictores de éxito / Drainage of clotted hemothorax by thoracoscopy: predictive factors of successful outcome

La toracoscopia tiene gran aceptacion como metodo terapeutico para el drenaje del hemotorax coagulado y aunque la conversion a toracotomia no se considera un fracaso, es importante determinar los factores que la ocasionan, con el fin de hacer mas segura y efectiva su aplicación. En este estudio se incluyen 61 pacientes con diagnosticos de hemotorax coagulado postraumatico que fue drenado por toracoscopia. El promedio de las edad es fue 28 años; el 96.7 por ciento de los pacientes fueron hombres y el 3.3 por ciento, mujeres. El promedio del tiempo quirurgico fue 59 minutos. La conversion de toracoscopia a toracotomia ocurrio en el 9.8 por ciento de los pacientes y en todos la causa fue el engrosamiento pleural. El mecanismo del trauma no se correlaciono con la conversion a toracotomia y con las complicaciones. El tiempo transcurrido entre el momento del trauma y la cirugia, aunque no fue estadisticamente significativo, se comporto como un factor importante relacionado con la presencia de complicaciones y la conversion a toracotomia. Hubo 9 (14.7 por ciento) complicaciones postoperatorias; 3 pacientes necesitaron una toracotomia para tratar su complicacion. Se considera que la toracoscopia es una tecnica segura y eficaz para el tratamiento del hemotorax coagulado postraumatico, independientemente de la edad, el sexo, el mecanismo del trauma y el tiempo de evolucion. Sin embargo, se debe tener en cuenta que despues del septimo dia, el porcentaje de conversion a toracotomia es mayor.

Tratamiento del hemotórax coagulado postraumático: toracoscopia vs. toracotomía / Thoracoscopy vs. thoracotomy in the treatment of coagulated post-traumatic hemotorax

Se presenta un ensayo clinico prospectivo, aleatorio que evalua el tratamiento del hemotorax coagulado mediante toracoscopia comparándolo con la toracotomia de limpieza convencional. El drenaje del hemotorax coagulado postraumático por toracoscopia es un metodo de fácil aprendizaje y realizacion, seguro y eficaz,, con las ventajas de menor tiempo quirurgico, menor incapacidad postoperatoria, reincorporacion laboral temprana y resultado estetico inobjetable.

Sphincter of Oddi manometry in healthy volunteers.

In this study we describe in detail the characteristics of sphincter of Oddi motor function in a large group of healthy subjects. Studies were obtained in 50 healthy volunteers. The findings showed a sphincter of Oddi segment that had a basal pressure of 14.8 +/- 6.3 mm Hg (X +/- SD). Phasic contractions were superimposed on the basal pressure. They had an amplitude of 119.7 +/- 32 mm Hg, a duration of 4.7 +/- 1 sec, and a frequency of 5.7 +/- 1.2 contractions/min. In 40 subjects the propagation sequence of phasic contractions could be evaluated and were simultaneous in 53%, antegrade in 35%, and retrograde in 11% of the waves. In 20 subjects, pressure measurements done at the common bile duct sphincter waves. In 20 subjects, pressure measurements done at the common bile duct sphincter were similar to those obtained at the pancreatic duct sphincter. In 10 subjects, pressure values obtained at the common bile duct sphincter within a week were similar. Our study should help to establish standards for normal manometric values of the sphincter of Oddi and emphasizes the importance of having a healthy volunteer group from which to obtain the normal values of sphincter of Oddi motor function.