Dario Birolini

Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience.

BACKGROUND Considerable skepticism still exists about the role of diagnostic laparoscopy in the evaluation of penetrating abdominal trauma. The reported experience with therapeutic laparoscopy has been limited. METHODS Retrospective analysis of a collective experience from three large urban trauma centers with 510 patients (316 stab wounds, 194 gunshot wounds) who were hemodynamically stable and had no urgent indications for celiotomy. RESULTS Laparotomy was avoided in 277 of the 510 patients (54.3%) either because of nonpenetration or insignificant findings on laparoscopy. All were discharged uneventfully after a mean hospital stay of 1.7 days. Twenty-six had successful therapeutic procedures on laparoscopy (diaphragmatic repair in 16 patients, cholecystectomy in 1 patient, hepatic repair in 6 patients, and closure of gastrotomy in 3 patients) with uneventful recovery. In the remaining 203 patients, laparotomy was therapeutic in 155. Fifty-two patients had nontherapeutic celiotomy for exclusion of bowel injuries or as mandatory laparotomy for penetrating gunshot wounds (19.7%). The overall incidence of nontherapeutic laparotomy was 10.2%. Complications from laparoscopy were minimal (10 of 510) and minor. CONCLUSIONS Laparoscopy has an important diagnostic role in stable patients with penetrating abdominal trauma. In carefully selected patients, therapeutic laparoscopy is practical, feasible, and offers all the advantages of minimally invasive surgery.

Hypertonic saline improves tissue oxygenation and reduces systemic and pulmonary inflammatory response caused by hemorrhagic shock.

BACKGROUND The treatment of hemorrhagic shock (HeS) with large volumes of fluid does not ensure an adequate peripheral perfusion or prevent inflammatory activation despite hemodynamic recovery. The purpose of this study was to compare the effect of hypertonic saline (HTS) and isotonic saline (IS) solutions on oxygenation, perfusion, tumor necrosis factor-alpha and interleukin-6 levels, accumulation of polymorphonuclear neutrophils, and pulmonary perivascular edema in the treatment of controlled HeS in rats. METHODS Wistar rats submitted to HeS for 50 minutes (mean arterial pressure, 45-50 mm Hg) were treated with IS at three times the bled volume or with 5 mL/kg HTS. RESULTS The animals treated with HTS presented higher oxygenation and perfusion indices (p < 0.0001); lower arterial lactate, tumor necrosis factor-alpha, and interleukin-6 levels (p < 0.0001); less pulmonary perivascular edema and polymorphonuclear neutrophil sequestration (p < 0.0001); and lower mortality (p < 0.01) than those that received IS. CONCLUSION HTS improved tissue oxygenation and perfusion and reduced systemic and pulmonary inflammatory responses compared with IS in the treatment of HeS in rats.

Standard examination system for laparoscopy in penetrating abdominal trauma.

BACKGROUND The high missed occult small bowel injuries (SBI) associated with laparoscopy in trauma (LIT) is a major reason why some surgeons still preclude LIT today. No standardized laparoscopic examination for evaluation of the peritoneal cavity is described for trauma. The objective of this article is to verify if a systematic standardized laparoscopic approach could correctly identify SBI in the peritoneal cavity for penetrating abdominal trauma (PAT). METHODS Victims with PAT were evaluated in a prospective, nonrandomized study. A total of 75 hemodynamically stable patients with suspected abdominal injuries were operated by LIT and converted to laparotomy if criteria were met: SBI and lesions to blind spot zones--retroperitoneal hematoma, injuries to segments VI or VII of the liver, or injuries to the posterior area of the spleen. Inclusion criteria were equivocal evidence of abdominal injuries or peritoneal penetration; systolic blood pressure >90 mm Hg and <3 L of IV fluids in the first hour of admission; Glasgow Coma Scale score >12; and age >12 years. Exclusion criteria were back injuries; pregnancy; previous laparotomy; and chronic cardiorespiratory disease. RESULTS Sixty patients were males and there were 38 stab wounds and 37 gunshot wounds. No SBI was missed, but a pancreatic lesion was undiagnosed due to a retroperitoneal hematoma. Twenty patients (26.6%) were converted. Unnecessary laparotomies were avoided in 73.33%. Therapeutic LIT was possible in 22.7%. Accuracy was 98.66% with 97.61% sensitivity and 100% specificity. CONCLUSIONS Standard systematic laparoscopic exploration was 100% effective to detect SBI in the peritoneal cavity. Conversion from LIT to laparotomy should be done if injuries to blind spot zones are found which are poorly evaluated by LIT. Therapeutic LIT is feasible in PAT.

Evaluation of Gastric Greater Curvature Invagination for Weight Loss in Rats

Background: Many bariatric endocopic or surgical procedures performed today reduce gastric capacity and/or induce an early sensation of satiety, alone or in combination with a distal enteric intervention. A form of prosthetic gastric wrap was used in the past for treating obesity with a high rate of reintervention. Nissen gastric fundoplication used in the treatment of gastroesophageal reflux disease induces a small but significant weight loss. We report the effect of gastric greater curvature invagination on weight in rats. Methods: 30 rats were randomly divided into 3 groups. 10 rats in the first group (sham) were anesthesized and weighed. The rats from the second group (lap) were in addition submitted to a laparotomy plus visceral manipulation. In the third group (inv), invagination of the greater curvature of the stomach was added. All animals were weighed on the 7th and 21st days. They were then autopsied on the 21st day. Results: The mean body weight of the invagination group became statistically less than the laparotomy and sham groups at 7 and 21 days. The mean weight of the peritesticular fat pad from the inv group was also significantly less than from the sham group but not different from the lap group. Conclusion: Gastric greater curvature invagination significantly decreases weight in rats.

Spontaneous intramural small bowel hematoma induced by anticoagulant therapy: review and case report

Of particular note among the causes of abdominal pain that necessitate surgery are appendicitis and intestinal obstruction. The most frequent causes of obstruction are adhesions (60%), hernias (15%), neoplasia (6%) and rare causes (6%). 2 In many cases, surgery comes to represent both a diagnostic and therapeutic measure. In some cases, however, we may be confronted by an obstructive condition in which more conservative measures are recommended. The aim of this article is to highlight the rare occurrence of acute abdominal obstruction due to spontaneous intramural small bowel hematoma resulting from the use of oral anticoagulants by reporting on a case attended at the General Surgery Service of the Clinical Surgery Division III of the Hospital das Clinicas - University of Sao Paulo Medical School (HC – FMUSP), as well as presenting a systematic review of the literature from the last 25 years.

Use of Pentastarch Solution in the Treatment of Patients with Hemorrhagic Hypovolemia: Randomized Phase II Study in the Emergency Room

Abstract. This study evaluates the hemodynamic effects of the administration of 10% pentastarch solution (PS) during the initial treatment of hypovolemia in trauma patients. This prospective randomized phase II study included trauma patients admitted to the emergency room with hemorrhagic hypovolemia: systolic blood pressure (SBP) < 90 mmHg. Upon admission, the patients were randomized to receive 10% PS (n= 12) or isotonic 0.9% NaCl solution (IS) (n= 11), infused intravenously in 250-ml boluses, repeated until SBP > 100 mmHg. Blood pressure, infused volumes necessary to maintain SBP, and overall survival rates were determined and compared between groups. SBP increased significantly following either IS (from 64.4 ± 9.2 mmHg to 111.1 ± 6.3 mmHg), or PS (from 63.7 ± 10.6 mmHg to 108.1 ± 9.8 mmHg) when compared to admission values (p < 0.05). Endovenous volumes infused were greater (p= 0.001) in IS patients (1420 ± 298 ml) than in PS patients (356 ± 64 ml). No blood was transfused into PS patients, compared to 370 ± 140 ml of red blood cells transfused into IS patients (p= 0.015). Mortality rates were similar in the two groups (p= 0.725). We concluded that PS is a safe, efficient method for inducing hemodynamic recovery of hypovolemic trauma patients, with a clear reduction in the intravenous volumes required for acute resuscitation.

Gut ischemia/reperfusion activates lung macrophages for tumor necrosis factor and hydrogen peroxide production.

BACKGROUND Gut ischemia followed by reperfusion (I/R) is implicated as a prime initiating event in the mechanism of multiple organ failure after trauma and hemorrhagic shock. Several lines of evidence indicate that macrophages are involved in this prime event. Our purpose was to evaluate hydrogen peroxide (H2O2) and tumor necrosis factor (TNF) production and phagocytosis by lung macrophages in a gut I/R model of multiple organ failure in rats. METHODS In the experimental group (I/R), Wistar rats (n = 35) were anesthetized and subjected to a median laparotomy, and the superior mesenteric artery was clamped for 45 minutes followed by 60 minutes of reperfusion. In the control group (LAP) (n = 37), animals underwent sham laparotomy. After the period of reperfusion, bronchoalveolar lavage (BAL) was performed and the resulting BAL cells were assayed for H2O2 production using the horseradish peroxidase-mediated red phenol oxidation method. TNF release was determined using the L929 cells bioassay. Zymosan phagocytosis by BAL macrophages was quantitated using phase microscopy. RESULTS H2O2 release in BAL cells of I/R rats (19.90 +/- 7.98 nmol/L/2 x 10(5) cells) is statistically higher than in the LAP group (10.92 +/- 5.01 nmol/L per 2 x 10(5) cells) (p = 0.0155), and the TNF production by BAL cells of the I/R group (38.09 +/- 20.79 units per 10(6) cells) was significantly higher than that of LAP rats (17.16 +/- 13.35 units per 10(6) cells) (p = 0.0281). Phagocytic activity of BAL mac. Macrophages of I/R rats was not statistically different from LAP animals. CONCLUSION These results suggest that BAL macrophage play a role in the mechanism of acute lung injury after trauma and hemorrhagic shock.

NEW CONCEPTS IN THE MANAGEMENT OF PATIENTS WITH PENETRATING ABDOMINAL WOUNDS

In the future, trauma research and care will have to become better, faster, and less expensive. Surgeons in the next millennium must be able to diagnose wounds, initiate correct procedures, and anticipate complications more accurately than before. Violent crime will not abate, nor will the proliferation of more powerful arms; these trends translate into graver traumatic wounds, giving the operating team less time to stabilize patients. Time management and team coordination are becoming key elements for patient survival, especially for patients with potentially fatal wounds, such as those to the heart. The authors have reduced the time from arrival to surgery to a few minutes. The keys to this feat are readiness, team coordination, and high morale. Financial resources will continue to be limited and allocated on a need-first basis. In the future, trauma centers will compete for dwindling funds. Technology is and always will be just a tool, whereas qualified trauma surgeons are irreplaceable, much more so than in any other surgical specialty. Observation, diagnosis, and surgery are, of course, greatly facilitated by ever-evolving technology, but since the time of Hippocrates, split-second decisions can ultimately be made only by the caregiver in the white smock. Trauma surgeons in the next millennium will have to exercise judgment based on knowledge, surgical skills, and contact with patients. To err is human, but in surgery, errors often cause death, and no machine will ever relieve surgeons of that burden.

Open pelviperineal trauma

The authors present their results in the management of 48 patients with complex pelviperineal injuries treated at the Surgical Emergency Ward of the University of São Paulo School of Medicine General Hospital. The distinct factors influencing the morbidity and mortality rates are discussed as well as the importance of an aggressive treatment in the initial approach of these patients. The following steps are virtually essential for the achievement of results comparable to those presented in the present protocol: exhaustive irrigation of the perineal wound with saline solution followed by surgical debridement and removal of all devitalized areas, maintenance of the wound open, early maturation transverse colostomy with total fecal flow diversion, periodic surgical revisions at intervals of 24 to 72 hours, large doses of antibiotic therapy, nutritional support with full parenteral feeding, and appropriate management of bone injuries and skin grafts. Adopting of measures proposed in this protocol yielded a decrease in mortality rate from 70% to 31.5%.

Injuries to the tracheobronchial tree in closed trauma

Seven cases of injury to the tracheobronchial tree in closed trauma of the thorax, treated by the surgical emergency service of the Hospital das Clínicas, University of São Paulo School of Medicine, during the period 1980-2 are described and compared with previously published cases. The diagnosis of the seven cases presented in this series was clinically suspected and endoscopically confirmed within 24 hours of injury, all patients being immediately submitted to reconstructive surgery; and except for one who failed to respond to initial resuscitation and died during surgery all the patients had a satisfactory postoperative course. Many previously reported cases of tracheobronchial injury by contrast have taken more than a month to be diagnosed; but for the best results such injuries must be repaired immediately. Awareness of the possibility of tracheobronchial injury in cases of violent chest trauma is important for early diagnosis; emphysema, dyspnoea, and pneumothorax are not always present, and absence of radiological and clinical signs of tracheobronchial injury does not exclude such injury. Bronchoscopy is the most important investigation for clinical diagnosis. Once the diagnosis has been made thoracotomy is nearly always required. Throughout the surgical procedure expert cooperation between anaesthetist and surgeon is essential. After operation prevention of further damage to the trachea depends on careful respiratory management.