Síndrome de Wünderlich por rotura de vena iliaca, secundario a trombosis venosa profunda / Wünderlich syndrome due to a ruptured iliac vein secondary to deep venous thrombosis

El síndrome de Wünderlich, o hematoma retroperitoneal espontáneo, secundario a una rotura espontánea de la vena iliaca es una entidad clínica poco común que constituye una urgencia médica. No está claro el desencadenante en muchos casos, proponiéndose diferentes hipótesis etiológicas relacionadas con factores hormonales, inflamatorios y/o mecánicos; y en este punto, puede ser importante valorar la existencia de un factor que desencadene la trombosis venosa profunda y que, secundariamente, se genere la rotura de la vena iliaca y el hematoma retroperitoneal. Presentamos un caso clínico donde la trombosis venosa pudo ser la causa de la rotura de la vena iliaca y realizamos una discusión del tema con base en la literatura médica encontrada

Wünderlich syndrome, or spontaneous retroperitoneal hematoma, secondary to spontaneous rupture of the iliac vein is a rare clinical entity and a medical emergency. Often the aetiology is difficult to identify and different hypotheses have been proposed, such as the presence of hormonal, inflammatory and/or mechanical factors. It may be important to assess the presence of a factor that triggered the deep vein thrombosis and secondary rupture of the iliac vein and retroperitoneal hematoma. We present a case where venous thrombosis could have caused rupture of the iliac vein and we discuss the entity in light of the current literature

Abordaje y manejo de las lesiones retroperitoneales traumáticas / Approach and Management of Traumatic Retroperitoneal Injuries

Las lesiones traumáticas retroperitoneales constituyen un desafío para el cirujano de traumatología. Ocurren generalmente en el contexto de un paciente politraumatizado, con múltiples lesiones asociadas y en el que los procedimientos invasivos tienen un rol preponderante en el diagnóstico de estas lesiones. El retroperitoneo es la región anatómica que presenta mayores tasas de mortalidad, por lo que el diagnóstico precoz y tratamiento de estas lesiones adquiere especial relevancia. El objetivo de este trabajo es presentar la evidencia científica publicada hasta el momento en cuanto a su prevalencia, mecanismo lesional, métodos diagnósticos y tratamiento mediante una revisión de la literatura internacional de los últimos 70 años. Como conclusión, en esta revisión sistemática se pone de manifiesto una creciente tendencia al manejo no quirúrgico de las lesiones que afectan el retroperitoneo

Traumatic retroperitoneal injuries constitute a challenge for trauma surgeons. They usually occur in the context of a trauma patient with multiple associated injuries, in whom invasive procedures have an important role in the diagnosis of these injuries. The retroperitoneum is the anatomical region with the highest mortality rates, therefore early diagnosis and treatment of these lesions acquire special relevance. The aim of this study is to present current published scientific evidence regarding incidence, mechanism of injury, diagnostic methods and treatment through a review of the international literature from the last 70 years. In conclusion, this systematic review showed an increasing trend towards non-surgical management of retroperitoneal injuries

Approach and Management of Traumatic Retroperitoneal Injuries. / Abordaje y manejo de las lesiones retroperitoneales traumáticas.

Traumatic retroperitoneal injuries constitute a challenge for trauma surgeons. They usually occur in the context of a trauma patient with multiple associated injuries, in whom invasive procedures have an important role in the diagnosis of these injuries. The retroperitoneum is the anatomical region with the highest mortality rates, therefore early diagnosis and treatment of these lesions acquire special relevance. The aim of this study is to present current published scientific evidence regarding incidence, mechanism of injury, diagnostic methods and treatment through a review of the international literature from the last 70 years. In conclusion, this systematic review showed an increasing trend towards non-surgical management of retroperitoneal injuries.

Diagnostic Laparoscopy for Trauma: How Not to Miss Injuries.

INTRODUCTION: Diagnostic laparoscopy (DL) is a well-accepted approach for penetrating abdominal trauma (PAT). However, the steps of procedure and the systematic laparoscopic examination are not clearly defined in the literature. The aim of this study was to clarify the definition of DL in trauma surgery by auditing DL performed for PAT at our institution, and to describe the strategies on how to avoid missed injuries. METHODS: The data of patients managed with laparoscopy for PAT from January 2012 to December 2015 were retrospectively analyzed. The details of operative technique and strategies on how to avoid missed injuries were discussed. RESULTS: Out of 250 patients managed with laparoscopy for PAT, 113 (45%) patients underwent DL. Stab wounds sustained 94 (83%) patients. The penetration of the peritoneal cavity or retroperitoneum was documented in 67 (59%) of patients. Organ evisceration was present in 21 (19%) patients. Multiple injuries were present in 22% of cases. The chest was the most common associated injury. Two (1.8%) iatrogenic injuries were recorded. The conversion rate was 1.7% (2/115). The mean length of hospital stay was 4 days. There were no missed injuries. In the therapeutic laparoscopy (TL) group, DL was performed as the initial part and identified all injuries. There were no missed injuries in the TL group. The predetermined sequential steps of DL and the standard systematic examination of intraabdominal organs were described. CONCLUSIONS: DL is a feasible and safe procedure. It accurately identifies intraabdominal injuries. The selected use of preoperative imaging, adherence to the predetermined steps of procedure and the standard systematic laparoscopic examination will minimize the rate of missed injuries.

Current trends in the management of hemodynamically unstable pelvic ring injuries.

PURPOSE OF REVIEW: Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries. RECENT FINDINGS: Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization. SUMMARY: Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.

Altered defaecatory behaviour and faecal incontinence in a video-tracked animal model of pudendal neuropathy.

AIM: The aim was to develop a behavioural animal model of faecal continence and assess the effect of retro-uterine balloon inflation (RBI) injury. RBI in the rat causes pudendal neuropathy, a risk factor for obstetric related faecal incontinence in humans. METHOD: Video-tracking of healthy rats (n = 12) in a cage containing a latrine box was used to monitor their defaecatory behaviour index (DBI) over 2 weeks. The DBI (range 0-1) was devised by dividing the defaecation rate (pellets per hour) outside the latrine by that of the whole cage. A score of 0 indicates all pellets were deposited in the latrine. Subsequently, the effects of RBI (n = 19), sham surgery (n = 4) and colostomy (n = 2) were determined by monitoring the DBI for 2 weeks preoperatively and 3 weeks postoperatively. RESULTS: The DBI for healthy rats was 0.1 ± 0.03 with no significant change over 2 weeks (P = 0.71). In the RBI group, 13 of 19 rats (68%) showed no significant change in DBI postoperatively (0.08 ±  -0.05 vs 0.11 ±  -0.07) while in six rats the DBI increased from 0.16 ±  -0.09 to 0.46 ± 0.23. The negative control, sham surgery, did not significantly affect the DBI (0.09 ± 0.06 vs 0.08 ± 0.04, P = 0.14). The positive control, colostomy, increased the DBI from 0.26 ± 0.03 to 0.86 ± 0.08. CONCLUSIONS: This is the first study showing a quantifiable change in defaecatory behaviour following injury in an animal model. This model of pudendal neuropathy affects continence in 32% of rats and provides a basis for research on interventions for incontinence.

Fractures of the pelvic ring.

Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.

Reversal of Anticoagulation With Dabigatran in an 82-Year-Old Patient With Traumatic Retroperitoneal Arterial Bleeding Using the New Antidote Idarucizumab: A Case Report.

Dabigatran etexilate is a direct oral anticoagulant used for the prevention of stroke in atrial fibrillation. Idarucizumab is a recently approved specific antidote that reverses the effect of dabigatran within minutes. We report the case of an 82-year-old patient with traumatic retroperitoneal arterial bleeding under anticoagulation with dabigatran etexilate. By administration of idarucizumab, we successfully normalized coagulation and saved the patient from an operation. In the course of the disease, a slight reincrease in dabigatran etexilate plasma levels was observed 2 days after the reversal, which could lead to a new onset of bleeding.

Trauma duodenal. Consecuencias del retraso en su diagnóstico / Duodenal trauma. Consequences of delay in diagnosis

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Large-magnitude Pelvic and Retroperitoneal Tissue Damage Predicts Organ Failure.

BACKGROUND: Pelvic and retroperitoneal trauma is a major cause of morbidity and mortality in multiply injured patients. The Injury Severity Score (ISS) has been criticized for underrepresenting and inaccurately defining mechanical injury. The influence of pelvic injury volume on organ dysfunction and multiple organ failure (MOF) has not been described. Through the use of CT, this investigation sought to precisely define volumes of mechanical tissue damage by anatomic region and examine its impact on organ failure. QUESTIONS/PURPOSES: (1) Do patients with MOF have a greater volume of pelvic and retroperitoneal tissue damage when compared with those without MOF? (2) In patients who sustained pelvic trauma, does the magnitude of pelvic injury differ in patients with MOF? (3) Does the magnitude of organ dysfunction correlate with pelvic tissue damage volume? METHODS: Seventy-four multiply injured patients aged 18 to 65 years with an ISS ≥ 18 admitted to the intensive care unit for a minimum of 6 days with complete admission CT scans were analyzed. Each identifiable injury in the head/neck, chest, abdomen, and pelvis underwent volumetric determination using CT to generate regional tissue damage volume scores. Primary outcomes were the development of MOF as measured by the Denver MOF score and the degree of organ dysfunction by utilization of the Sequential Organ Failure Assessment (SOFA) score. Mean pelvic and retroperitoneal tissue damage volumes were compared in patients who developed MOF and those who did not develop MOF using Student's t-test. Among patients who sustained pelvic injuries, we compared mean volume of tissue damaged in patients who developed MOF and those who did not. We assessed whether there was a correlation between organ dysfunction, as measured by the SOFA score as a continuous variable, and the volume of pelvic and retroperitoneal tissue damage using the Pearson product-moment correlation coefficient. RESULTS: The average volume of tissue damage was greater in patients with MOF when compared with those without (MOF: 685.667 ± 1081.344; non-MOF: 195.511 ± 381.436; mean difference 490.156 cc [95% confidence interval {CI}, 50.076-930.237 cc], p = 0.030). Among patients who sustained pelvic injuries, those with MOF had higher average tissue damage volumes than those without MOF (MOF: 1322.000 ± 1197.050; non-MOF: 382.750 ± 465.005; mean difference 939.250 [95% CI, 229.267-1649.233], p = 0.013). Organ dysfunction (SOFA score) correlated with higher volumes of pelvic tissue damage (r = 0.570, p < 0.001). CONCLUSIONS: This investigation demonstrated that greater degrees of pelvic and retroperitoneal tissue damage calculated from injury CT scans in multiply injured patients is associated with more severe organ dysfunction and an increased risk of developing MOF. Early identification of polytrauma patients at risk of MOF allows clinicians to implement appropriate resuscitative strategies early in the disease course. Improved stratification of injury severity and a patient's anticipated clinical course may aid in the planning and execution of staged orthopaedic interventions. Future avenues of study should incorporate the ischemic/hypoperfusion component of pelvic injury in conjunction with the mechanical component presented here for improved stratification of multiply injured patients at higher risk of MOF. LEVEL OF EVIDENCE: Level III, prognostic study.

Mononeuropatía femoral de etiología poco habitual / Femoral mononeuropathy of unusual etiology

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Hematoma retroperitoneal espontáneo (syndrome de Wünderlich): A propósito de dos casos / Spontaneous Retroperitoneal Hemorrhage (Wünderlich Syndrome): A Two-Case Report

OBJETIVO: Revisar las distintas etiologías, diagnóstico y tratamiento de la hemorragia retroperitoneal espontánea. Métodos/RESULTADOS: Presentamos dos casos de abdomen agudo, secundario a hemorragia retroperitoneal (síndrome de Wünderlich) por rotura espontánea renal. En dos varones de 59 y 79 años de edad, asociado a litiasis renal y quiste renal. Con una presentación frecuente de dolor abdominal, masa palpable y hematuria, lo que constituye la tríada de Lenk. Entre el 15-20% comienzan con un cuadro de shock hipovolémico por sangrado. CONCLUSIONES: El diagnóstico de abdomen agudo por hemorragia retroperitoneal requiere una combinación de información clínica y pruebas de imagen. Resaltamos la importancia de la tomografía computarizada helicoidal con contraste endovenoso para un diagnóstico definitivo, el cual demostró el punto activo de sangrado, la cuantía de la hemorragia y el origen probable, nos sirvió como examen guía para la planificación terapéutica

OBJECTIVE: To review the etiology, diagnosis and treatment of spontaneous retroperitoneal hemorrhage. Methods/RESULTS: We report the cases of two men 59 and 79 years old, presenting acute abdominal pain secondary to retroperitoneal bleeding (Wünderlich's syndrome) due to spontaneous renal rupture caused by urolithiasis and angiomyolipoma respectively. CONCLUSIONS: Diagnosis of acute abdomen due to retroperitoneal hemorrhage requires a combination of clinical information and imaging tests. We emphasize the role of IV contrast helical CT scan for a definitive diagnosis, which demonstrated the active bleeding point, the amount of hemorrhage, and the probable origin, and provided guide for therapeutic planning

The management of retroperitoneal haematoma discovered at laparotomy for trauma.

AIM: To review our local experience with presentation and management of retroperitoneal haematomas (RPH) discovered at laparotomy and factors affecting outcome. METHODS: Patients with retroperitoneal haematomas (RPHs) were identified from a prospective database. Data collected included demographics, clinical presentation, zones and organs involved, management and outcome. RESULTS: Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of whom were male (M:F=15:1). Mean age was 28.8 (SD 10.6) years and median delay before surgery was 7h. The injury mechanisms were firearms (109), stabs (24), and blunt trauma (12). Twenty-four patients (17%) presented with shock. There were 58 Zone I, 69 Zone II, and 38 Zone III haematomas. The median injury severity score (ISS) was 9. Fifty-two patients (36%) developed complications and 26 (18%) patients died. Sixty-four (44%) patients required ICU with median ICU stay of 3 days. All Zone I injuries were explored; Zones II and III were explored selectively. The mortality for Zones I, II, III and IV was 14%, 4%, 29% and 35%, respectively. Mortality was highest for blunt trauma and lowest for stabs (p=0.146). Twelve of 24 patients with shock died (50%) compared to 14 of 121 (12%) without shock (p<0.0001). Eighteen of 64 patients with <6-h delay before surgery died (28%) compared to 8 of 81 (10%) with >6-h delay (p<0.017). Mortality increased with increasing ISS. Median hospital stay was 8 days. CONCLUSION: RPH accounted for 30% of abdominal trauma. Injury mechanism, presence of shock, delay before surgery and ISS showed a significant association with mortality.

Morbimortalidad de hematoma retroperitoneal traumático en el Hospital Nacional Daniel Alcides Carrión Enero del 2007 a Diciembre del 2011 / Morbidity and mortality of traumatic retroperitoneal hematoma at the National Hospital Daniel Alcides Carrion from January 2007 to December 2011

El hematoma retroperitoneal traumático (HRP) es una entidad poco frecuente cuya repercusión clínica varía, de acuerdo a los órganos retroperitoneales que sean lesionados, en función del agente causal, la velocidad y la cuantía de la hemorragia; se asocia con altas tasas de complicaciones y letalidad. En el Perú, no se tiene registro de la epidemiologia de esta patología, lo que dificulta la toma de decisiones precisas en su manejo. METODOS: Se realizó un estudio descriptivo, transversal y retrospectivo en pacientes mayores de 15 años con diagnóstico de HRP, que ingresaron a la emergencia de cirugía del Hospital Nacional Daniel Alcides Carrión, por trauma abdominal (Enero del 2007 - Diciembre del 2011). Se revisaron las historias clínicas y libro de reporte operatorio. OBJETIVO PRINCIPAL: Identificar la morbimortalidad que causa el Hematoma Retroperitoneal Traumático en pacientes mayores de 15 años atendidos en el servicio de Cirugía en el Hospital Nacional Daniel Alcides Carrión, en el periodo Enero 2007 a Diciembre del 2011. RESULTADOS: Se obtuvo una muestra de 81 pacientes con los criterios de inclusión; 95 por ciento fueron de sexo masculino. El rango de edad más frecuente fue de 15 a 34 años. La incidencia de trauma abierto fue de 77 por ciento; y de trauma cerrado, de 23 por ciento, siendo el principal mecanismo de lesión el producido por proyectil de arma de fuego (61.7 por ciento). El diagnóstico se realizó en el intraoperatorio en un 77 por ciento y por tomografía en 15 por ciento. Se realizó tratamiento quirúrgico en el 83 por ciento. El hematoma retroperitoneal se localizó con mayor frecuencia en la Zona II (70 por ciento), las estructuras lesionadas que predominaron fueron la vena cava en la Zona I (50 por ciento), los riñones en la Zona II (40 por ciento) y los vasos de mediano calibre en la Zona III (22 por ciento). La principal lesión asociada fue el trauma yeyunal. Se determinó una mortalidad de 3,7 por ciento. CONCLUSIÓN: El hematoma...

The traumatic retroperitoneal hematoma (RPH) is an uncommon clinical disease whose effect varies depending on the retroperitoneal organs that are injured, according to the causal agent, the velocity and amount of bleeding; it's associated with high rates of complications and mortality. In Peru, there is no register of the epidemiology of this disease, which difficulties the decision of an adequate management. METHODS: It has made a descriptive, cross-sectional and retrospective study in patients older than 15 years diagnosed with RPH, admitted to the emergency of surgery of Daniel Alcides Carrion National Hospital with diagnosis of abdominal trauma (January 2007 - December 2011). Medical histories and book of surgery report were reviewed. PRINCIPAL OBJECTIVE: To identify the morbidity and mortality that causes Traumatic Retroperitoneal hematoma in patients older than 15 years treated in the Surgery Service of the National Hospital Daniel Alcides Carrion in the period January 2007 to December 2011. RESULTS: A sample of 81 patients was obtained with the inclusion criteria; 95 per cent were male gender. The most common age range was 15 to 34 years. The incidence of open trauma was 77 per cent; whereas closed trauma, 23 per cent, being the main mechanism of injury produced by projectile gun (61.7 per cent). The diagnosis was made intraoperative in 77 per cent and 15 per cent for tomography. Surgical treatment was made in 83 per cent. The retroperitoneal hematoma was located more frequently in Zone II (70 per cent), the principal structures that were injured were vena cava in Zone I (50 per cent), kidney in Zone II (40 per cent) and medium caliber vessels in Zone III (22 per cent). The principal associated lesion was jejunal trauma. A mortality of 3.7 per cent was determined. CONCLUSION: Traumatic retroperitoneal hematoma has its highest incidence in adolescents and young adult male patients with a history of drug dependence. The diagnosis was mainly done by...

Isolated pediatric duodenal rupture after horse hoof kick / Rotura duodenal aislada en un niño tras una coz de un caballo

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Adrenal trauma: medical and surgical emergency.

A 35-year-old man was admitted to hospital in a state of haemorrhagic shock after a road traffic accident. A right adrenal gland injury associated with a retroperitoneal haematoma was diagnosed by CT scan. Haemostatic surgery (without adrenal gland resection) was performed instead of angioembolisation because of an associated abdominal compartment syndrome. The outcome was favourable. The objective of this case report is to illustrate the importance of the early diagnosis of adrenal gland injuries after trauma which, though uncommon and frequently overlooked or discovered fortuitously by CT scan, can be life-threatening. Angioembolisation or surgery may be necessary in cases of uncontrolled bleeding or the development of abdominal compartmental syndrome.

Management of infected caval filter with simultaneous aortic pseudoaneurysm and retroperitoneal perforation: a case report and literature review.

Inferior vena cava (IVC) filters have been reported to have complication rates up to 35%. Penetration of surrounding retroperitoneal structures is an uncommon, but potentially serious, complication, with several reports in the literature. We present a unique case of a 34-year-old intravenous drug user with infected IVC filter struts penetrating multiple structures simultaneously. Definitive operative management was necessary for removal of filter struts from the aorta, the second part of the duodenum and the iliopsoas muscle. Drainage and debridement of an associated iliopsoas abscess was performed, followed by aortic and caval reconstruction.