José Ramón Cano García

TEMLA: nueva técnica para el tratamiento de la recidiva del cáncer de tiroides

La extirpación quirúrgica de los 2 casos que presentamos no planteó dificultades técnicas y estuvo exenta de complicaciones, por lo que coincidimos con otros autores en que este debe ser el tratamiento de elección. El estudio de estas lesiones mediante USE proporciona información útil para decidir la vı́a de abordaje y seleccionar aquellos casos idóneos para su extirpación endoscópica. Finalmente, recordamos que aunque se trate de una patologı́a poco frecuente, puede ser causa de morbididad y mortalidad importante por lo que es recomendable un tratamiento precoz.

Uso de barras de pectus en la reconstrucción de defectos complejos de la pared torácica anterior

1. Chaudhry R, Mahajan RK, Diwan A, Khan S, Singhal R, Chandel DS, et al. Unusual presentation of enteric fever: three cases of splenic and liver abscesses due to Salmonella typhi and Salmonella paratyphi A. Trop Gastroenterol. 2003;24: 198–9. 2. Edelson K. A 6-year-old boy with shoulder pain. Pediatric Annals. 2011;40: 342–4. 3. Nelken N, Ignatius J, Skinner M, Christensen N. Changing clinical spectrum of splenic abscess. A multicenter study and review of the literature. Am J Surg. 1987;154:27–34. 4. Debeuckelaere S, Schoors DF, Buydens P, Du Ville L, Spapen HD, Reynaert HM, et al. Splenic abscess: a diagnostic challenge. Am J Gastroenterol. 1991;86: 1675–8. 5. Choudhury SR, Debnath PR, Jain P, Kushwaha AS, Puri A, Chadha R, et al. Conservative management of isolated splenic abscess in children. J Ped Surg. 2010;45:372–5.

Hernia tóraco-abdominal postraumática

Hernias through the intercostal spaces are rare and few cases have been reported in the literature. They appear as a consequence of torn intercostal muscles, which allow the hernial sac to protrude with either lung parenchyma or abdominal viscera in its interior, when the intercostal space is low or when there is associated trauma with diaphragmatic rupture. We present the case of a large intercostal post-traumatic thoracic hernia with herniation of abdominal content. As a review of the literature provides no evidence-based recommendations for treatment, we report our experience in the surgical repair of this infrequent lesion. The patient is a 57-year-old obese male with COPD and hypertension who reported a history of chest trauma with a series of left rib fractures (from the 8th to the 11th) and hemothorax that required hospitalization and pleural drainage just 6 months earlier. He came to our consultation due to a painful and palpable mass in the ribcage area that had been previously injured. Thoracoabdominal CT confirmed multiple rib fractures that had not consolidated in the region of the posterior ribcage and herniation of abdominal content (Fig. 1a). Examination revealed truncal asymmetry caused by a soft, elastic, reducible herniated mass, and an extensive hernial orifice was palpated through the intercostal spaces (Fig. 1b). Preoperative nutritional therapy was initiated, and we decided on surgery. A lateral thoracotomy was performed over the hernia defect, which revealed several costal pseudoarthrosis in the area of the left 9th and 10th ribs with protruding abdominal content. We proceeded with the reduction of the hernia and approximation and cerclage of both ribs with thick, slow-absorbing sutures. Four months later, a symptomatic recurrence of the hernia was observed with a more anterior component, requiring reoperation. In this case, the lower half of the left rib cage was completely dissected, the fractured bone edges were refreshed, and plate osteosynthesis was performed with Judet struts along with approximation of the costal spaces using intercostal sutures (Fig. 2b). The abdominal content was reduced and the abdominal wall was closed and reinforced with synthetic mesh. The follow-up thoracic CT 3 months after surgery confirmed the integrity of the chest wall (Fig. 2a) and one year later the patient continues to be asymptomatic with no signs of recurrence. Herniations through the chest wall are very uncommon events that can arise after trauma or surgery, although there have also been reports of cases of herniations after intense physical effort, such as energetic coughing, vomiting or defecation. Mean age at presentation is after 50, and associations have been identified with COPD, obesity and asthma. In the case of COPD, the characteristic progressive weakness of the chest muscles in addition to frequent cough and, eventually, the existence of underlying

Ganglioneuroma mediastínico, un hallazgo fortuito en metastasectomía pulmonar y hepática de tumor de células germinales

152 Cir Esp. 2008;83(3):150-9 administracion diaria de dosis bajas. La agregacion plaquetaria se inhibe y alcanza una concentracion maxima estable despues de 4-7 dias, y por ello son necesarios 7 dias, despues de la ultima dosis, para que la funcion plaquetaria se restablezca. Recientemente, Payne et al investigaron el efecto del uso combinado del clopidogrel y la aspirina en el tiempo de sangria en voluntarios sanos, observaron que, tras 2 dias de tratamiento con clopidogrel 75 mg/dia y AAS 150 mg/dia, el tiempo de sangria era 3,4 veces mayor que el basal. La cirugia no demorable imposibilita actuar de manera acorde con lo establecido en las guias sobre uso de farmacos antiagregantes plaquetarios, ya que no es posible su demora un minimo de 6 semanas para minimizar los riesgos, ni es posible la sustitucion de los antiagregantes “mayores” (aspirina y tienopiridinas) por antiinflamatorios no esteroideos de vida media corta y con efectos antiagregantes reversibles. En la actualidad, es frecuente que tanto cirujanos como anestesiologos se encuentren con pacientes tratados con este tipo de farmacos, tanto en cirugia electiva como de urgencia, lo que plantea frecuentes controversias entre ambas especialidades en lo que se refiere al momento de realizar la intervencion. En nuestro caso, dado que nos encontrabamos ante una hemorragia grave, favorecida en gran medida por la toma de 2 antiagregantes, el tratamiento incluyo la transfusion de plaquetas, a pesar de aumentar asi el riesgo de trombosis coronaria y reinfarto, como posiblemente sucedio en nuestro enfermo. En ausencia de guias que orienten ante este tipo de situaciones, los riesgos y beneficios de nuestras actuaciones deberan valorarse ad hoc para cada paciente, considerando dos aspectos fundamentales: la posibilidad de complicaciones cardiologicas y la tecnica quirurgica, incluyendo aspectos como duracion, agresividad y sangrado.