Tamer Karsidag

Síndrome de exanguinación: factores predictivos e indicativos para la institución de la cirugía de control de daños

La exanguinación es una entidad muy temida, pero de ninguna manera desconocida para el cirujano de traumatismo. El aumento de la violencia en nuestra sociedad, junto con la mejoría de los sistemas de urgencias, que permiten el traslado rápido de lesionados, han facilitado la asistencia de pacientes que antes no habrían sobrevivido hasta llegar a un centro de traumatología1 y, sin embargo, la definición del cuadro clínico y su correcto manejo aún no están del todo bien establecidos. Anderson2 estableció que un paciente que se desangra es aquel que “pierde toda su volemia en minutos”. Trunkey3 describió las hemorragias en función del flujo; así, la hemorragia grave es aquella con una pérdida sanguínea mayor de 150 ml/min. El manual del Programa Avanzado de Apoyo Vital en Trauma (ATLS) del Colegio Americano de Cirujanos4 define la exanguinación como el cuadro clínico de shock hipovolémico en pacientes que han perdido el 40% o más de su volemia y en los que hay un riesgo inminente de muerte. No hay duda de que todos estos intentos establecen que se trata de una situación crítica, pero ninguno de ellos ofrece una definición completa de la exanguinación como síndrome clínico, ni fisiológica, ni bioquímicamente. Asensio1,5 ha definido la exanguinación como la peor manifestación del shock hipovolémico de la siguiente forma: “La exanguinación es la forma más grave de hemorragia. Generalmente está producida por lesiones en los componentes principales del sistema cardiovascular, en las vísceras sólidas intraabdominales, o en ambos. Es una hemorragia en la que hay una pérdida inicial de la volemia del 40%, seguida de una pérdida superior a 250 ml/min y, si no se controla, el paciente perderá la mitad de su volumen circulatorio en 10 min”. Es decir, que la exanguinación implica una velocidad de pérdida de volumen circulatorio tal que no puede ser repuesta por medidas de resucitación habituales y, por ello, requiere la intervención quirúrgica inmediata1,5. El paciente en esta situación precisará al más experimentado de los cirujanos de traumatismos y el más preparado de los centros de traumatismos. Con esta revisión de la experiencia de nuestro centro en este proceso patológico pretendemos ofrecer la descripción de las lesiones con más riesgo de exanguinación, según la definición previamente propuesta, así como las recomendaciones para la adecuada resucitación y tratamiento de estos enfermos.

Traumatismos duodenales: lesiones complejas

Resumen Las lesiones traumaticas del duodeno son infrecuentes y representan cerca del 4% de las lesiones abdominales, pero conllevan una tasa de morbimortlidad significativa, por lo que su reconocimiento y tratamiento precoz es primordial. El objetivo de este trabajo es presentar una descripcion concisa de la perspectiva historica y de la anatomia de este organo. Esta ultima cobra especial interes a la hora de la clasificacion y el manejo de la lesion duodenal. Asimismo, describiremos los metodos de diagnostico a nuestro alcance en la evaluacion del traumatismo duodenal y la importancia de un conocimiento amplio de las tecnicas quirurgicas mas utilizadas. Por ultimo, realizaremos un analisis profundo de los rangos de morbilidad y mortalidad de estas lesiones basandonos en una extensa revision de la bibliografia actual y aportaremos nuestra experiencia en el manejo de este tipo de lesiones en un centro urbano de traumatismo de nivel I.

Alpha-1 protease inhibitor and antichymotrypsin levels in acute pancreatitis

BACKGROUND Acute pancreatitis with high mortality of severe onset is still a major problem in medicine. Early identification of the severity of the disease is critical for effective treatment. Many markers have been tried and are still being tested. The ideal marker should be able to identify the cases and distinguish between mild and severe. METHODS This prospective study included 34 cases (14 males, 20 females, mean age: 58 years) of acute pancreatitis and 33 cases (17 males, 16 females, mean age: 53 years) as a control group. Mild (n=29) and severe (n=5) cases were compared with respect to serum levels of amylase, C-reactive protein (CRP), alpha-1-protease inhibitor, and antichymotrypsin on admission and 24 and 48 hours (h) after admission. RESULTS Alpha-1 protease inhibitor and antichymotrypsin levels were significantly elevated in the first 24 h; however, CRP peaked after 48 h in the acute pancreatitis group. While CRP showed significantly higher concentrations in patients with severe pancreatitis, alpha-1-protease inhibitor and antichymotrypsin levels changed slightly, but without significance, in severe cases. CONCLUSION Alpha-1 protease inhibitor and antichymotrypsin are early events in acute pancreatitis, with high levels on admission. Activation of these variables declines after 24 h. These markers may have early diagnostic value in patients with acute pancreatitis. Because neither of them is good at discrimination of mild and severe cases in the disease, they should not be incorporated into routine clinical investigations.

Traumatismos pancreáticos: Lesiones complejas, tratamientos difíciles

Resumen Las lesiones traumaticas del pancreas son infrecuentes y representan aproximadamente el 4% de las lesiones abdominales, pero conllevan una tasa de morbimortlidad significativa, por lo que su reconocimiento y tratamiento precoz es primordial. El objetivo de este trabajo es presentar una descripcion concisa de la perspectiva historica y de la anatomia de este organo. Esta ultima cobra especial interes en la clasificacion y manejo de la lesion pancreatica. Asimismo, describiremos los metodos de diagnostico a nuestro alcance en la evaluacion del traumatismo pancreatico, asi como la importancia de disponer de un conocimiento amplio de las tecnicas quirurgicas mas utilizadas. Por ultimo, realizaremos un analisis profundo de los rangos de morbilidad y mortalidad de estas lesiones basandonos en una extensa revision de la bibliografia actual y aportando nuestra experiencia en el manejo de este tipo de lesiones en un centro urbano de trauma de nivel I.

The analysis of 89 patients that performed tube thoracostomy by general surgeons

Objective Death due to thoracic trauma accounts for 20% of all trauma deaths. The aim of this study was to discuss the approach applied by general surgeons to thoracic trauma in our center. Material and Methods A total of 89 patients (82 male, 7 female; mean age: 26.8 years; range: 7 to 77 years) with thoracic trauma who were admitted to the emergency department and underwent thoracostomy performed by general surgeons between January 2008 and December 2013 were retrospectively analyzed. Results Penetrating trauma was found in 61 patients (68%); this was the most common cause of thoracic trauma. Pneumothorax, the most common clinical sign, was found in 57 patients (64%). Abdominal pathologies, the most common concomitant extra-thoracic pathologies, were found in 17 patients (19%). Fifteen patients (17%) underwent laparotomy due to intra-abdominal organ injuries. Splenic trauma and diaphragmatic injury were detected in five patients. Complications were seen in two patients (2.2%): one had an air leak and one had persistent pneumothorax. Three patients with multi-trauma died in the early period due to additional pathologies. No mortality was seen in any patient due to thoracic trauma. Conclusion All general surgeons should be highly familiar with approaches to thoracic trauma, and necessary interventions should be performed in emergency situations. It is also essential to correctly identify patients who require timely and appropriate referral to a tertiary center to reduce the rates of mortality and morbidity.

Prosthetic Mesh Repair for Incarcerated Inguinal Hernia.

BACKGROUND Incarcerated inguinal hernia is a commonly encountered urgent surgical condition, and tension-free repair is a well-established method for the treatment of non-complicated cases. However, due to the risk of prosthetic material-related infections, the use of mesh in the repair of strangulated or incarcerated hernia has often been subject to debate. Recent studies have demonstrated that biomaterials represent suitable materials for performing urgent hernia repair. Certain studies recommend mesh repair only for cases where no bowel resection is required; other studies, however, recommend mesh repair for patients requiring bowel resection as well. AIM The aim of this study was to compare the outcomes of different surgical techniques performed for strangulated hernia, and to evaluate the effect of mesh use on postoperative complications. STUDY DESIGN Retrospective cross-sectional study. METHODS This retrospective study was performed with 151 patients who had been admitted to our hospitals emergency department to undergo surgery for a diagnosis of incarcerated inguinal hernia. The patients were divided into two groups based on the applied surgical technique. Group 1 consisted of 112 patients treated with mesh-based repair techniques, while Group 2 consisted of 39 patients treated with tissue repair techniques. Patients in Group 1 were further divided into two sub-groups: one consisting of patients undergoing bowel resection (Group 3), and the other consisting of patients not undergoing bowel resection (Group 4). RESULTS In Group 1, it was observed that eight (7.14%) of the patients had wound infections, while two (1.78%) had hematomas, four (3.57%) had seromas, and one (0.89%) had relapse. In Group 2, one (2.56%) of the patients had a wound infection, while three (7.69%) had hematomas, one (2.56%) had seroma, and none had relapses. There were no statistically significant differences between the two groups with respect to wound infection, seroma, hematoma, or relapse (p>0.05). In Group 3, it was observed that one (6.7%) of the patients had wound infections, while one (6.7%) had a hematoma, one patient (6.7%) had seroma, and none had relapses. In Group 4, seven (7.2%) of the patients had wound infections, while one (1%) had a hematoma, three (3%) had seromas, and one (1%) had a relapse. There were no significant differences between the two groups with respect to wound infection, seroma, hematoma, or relapse (p>0.05). CONCLUSION In urgent groin hernia repair surgeries, polypropylene mesh can be safely used even in the patients undergoing bowel resection.

Successful endoscopic removal of a foreign body in the rectum.

Foreign bodies are most frequently identified in the esophagus and rectum in the gastrointestinal system. In 80%-90% of cases, foreign bodies can be excreted through the gastrointestinal system without any medical treatment administered (1,2). Usually with sexual intentions, various bodies are reported to be inserted into the rectum. An endoscopic intervention through the anal route is primarily preferred to remove these bodies. Here, we report a male patient with a rectal foreign body and successful endoscopic removal.