Our experience of emergency colorectal injury as a result of abdominal trauma

Objective: In the present study, we aimed to examine the treatments and their outcomes in cases with colon injuries after blunt and penetrating abdominal traumas. Materials and Methods: Twenty-six patients who underwent a laparotomy and were found to have a colon injury due to blunt abdominal trauma, penetrating stab injury, gunshot injury, and traffic accident were included. All patients were admitted into the emergency outpatient clinic of Gazi Yasargil Training and Research Hospital General Surgery Clinic between 2016 and 2020. The records of the cases were analyzed retrospectively. Results: Colon injuries were detected in 26 cases. All 26 (100%) cases were males with an average age of 29.80 ± 11.4 (range: 17-60) years old. Colon injuries observed during emergency operations included 18 (69.23%) patients with a GSI (gunshot injuries), 3 (11.53%) with penetrating stab injuries, 4 (15.38%) who were a part of traffic accidents and 1 (3.85%) patient with a blunt abdominal trauma. A primary colon repair was performed in 10 patients. Five patients underwent a colon resection and there were end colostomies. Four patients underwent a loop ileostomy after a colon resection and anastomosis. Colon resections with anastomoses were performed in seven patients. The mean hospitalization period was 26 ± 29.28 days. Conclusion: Patients should be classified intraoperatively with findings, such as peritoneal contamination, degree of colon injury, duration of the injury, and any accompanying injuries. (AU)

Atuação em urgência e emergência a partir da psicologia junguiana / The pratice in an emergency service based on jungian psychology / La práctica en la urgencia y emergencia desde la psicología junguiana

Este artigo é um relato de experiência cujo objetivo é refletir sobre a atuação de uma psicóloga no contexto da urgência e emergência no hospital a partir da psicologia jungiana. Utilizou-se como método o recurso da sistematização da experiência, que consiste em sua interpretação crítica, cujo foco é o ordenamento e a reconstrução das experiências para explicitar a lógica do processo vivido. Por meio da reflexão de situações clínicas foi possível proporcionar um lugar para a subjetividade diante do disruptivo e da objetividade institucional do hospital. Teoricamente, o texto descreve as experiências de atendimento hospitalar, espaço em que urge o inesperado e o desconhecido. Aposta-se no simbolismo como movimento da psique para lidar com aquilo que o sujeito ainda não pode nomear, significar, incluindo a vulnerabilidade, as perdas e a questão da morte e do luto, este entendido como a ruptura de um vínculo. Dessa forma, a psicologia analítica se volta para como a entrada no hospital e a fugacidade do contexto de urgência e emergência afetam a psique dos sujeitos atendidos e de que forma esse psiquismo reage às vivências disruptivas e inesperadas.(AU)

This work is an experience report whose objective is to reflect on the role of a psychologist in the context of urgency and emergency in the hospital from the perspective of Jungian psychology. The resource of systematization of the experience was used as method, which consists of a critical interpretation, whose focus is the ordering and reconstruction of experiences to explain the logic of the process experienced. With the reflection of clinical situations, it was possible to provide a place for subjectivity in the face of the disruptive and the institutional objectivity of the hospital. Theoretically, the text describes the experience of entry in a hospital, a place in which the unexpected and the unknown are faced. We believe on symbolism as a movement of the psyche to deal with what the patient cannot yet name or give a meaning, including vulnerability, losses, and the issue of death and grief, this last one understood as the rupture of a link. Thus, analytical psychology will focus on how the entry in a hospital and the fleetingness of the emergency context affect the psyche of the patients and how this psyche reacts to the disruptive and unexpected experiences.(AU)

Este reporte de experiencia pretende reflejar sobre el papel de una psicóloga en el contexto de urgencia y emergencia en el hospital desde la perspectiva de la psicología junguiana. El método utilizado fue el recurso de sistematización de la experiencia, que consiste en una interpretación crítica, cuyo enfoque es el ordenamiento y reconstrucción de experiencias para explicar la lógica del proceso vivido. A partir del reflejo de situaciones clínicas se logró dar lugar a la subjetividad frente a la objetividad institucional del hospital. Teóricamente se describen las vivencias en la atención hospitalaria, un espacio donde se encuentra lo inesperado y lo desconocido. Se considera el simbolismo como un movimiento de la psique para lidiar con lo que el sujeto aún no puede nombrar, incluidas la vulnerabilidad, las pérdidas y el tema de la muerte y el dolor, este último comprendido como un quiebre del vínculo. De esta manera, la psicología analítica se centrará en cómo la admisión al hospital y la fugacidad del contexto de emergencia afectan la psique de los sujetos atendidos y cómo esta psique reacciona a estas experiencias disruptivas e inesperadas.(AU)

Surgical management of an abdominal impalement injury: a case report / Manejo quirúrgico de una lesion por empalamiento abdominal: reporte de caso

Impalement injuries are a complex and rare type of penetrating abdominal trauma that happens when an object such as a post or a pole penetrates a person injuring several organs, making it a life-threatening situation in which time and correct management play an important part in the survival of the patient. A 37-year-old man suffered abdominal impalement injury with a metal signal post, penetrating the left flank of the abdomen. On examination, there is a hypoventilated left hemithorax with intercostal retractions, increased heart rate, weak distal pulses, delayed capillary refill, and pale skin. A 1-meter-long metal post (approximately 7cm diameter) penetrates the left flank with the entry in the posterior lumbar region. Abdominal viscera, omentum, intestinal content, and ischemic loops of the small intestine are visible. An exploratory laparotomy was performed; left hemicolectomy, end colostomy and Hartmann procedure, resection of the affected jejunum, and end-to-end anastomosis were performed. On the ninth postoperative day, an abdominal tomography was performed due to the presence of fever peaks, which reported thrombosis of the left renal artery and emphysematous pyelonephritis, with the presence of a left pararenal collection. A simple left nephrectomy was performed. Postoperative surveillance was satisfactory during the following 5 days. The patient was discharged. An impaled injury is a complex lesion that needs special attention from the medical field for correct management. Although there is some literature about it, we encourage more research to be done about impalement injuries.

Las lesiones por empalamiento son un tipo de traumatismo abdominal penetrante complejo y raro de que se produce cuando un objeto, como un poste o una vara, penetra a una persona lesionando varios órganos, lo que la convierte en una situación potencialmente mortal en la que el tiempo y el manejo correcto juegan un papel importante en la supervivencia del paciente. Un hombre de 37 años sufrió una herida por empalamiento abdominal con un poste de señales de metal, penetrando el flanco izquierdo del abdomen. A la exploración física, hay un hemitórax izquierdo hipoventilado con retracciones intercostales, aumento de la frecuencia cardíaca, pulsos distales débiles, relleno capilar retrasado y piel pálida. Un poste metálico de 1 metro de largo (aproximadamente 7 cm de diámetro) penetra el flanco izquierdo con entrada en la región lumbar posterior. Son visibles las vísceras abdominales, el epiplón, el contenido intestinal y las asas isquémicas del intestino delgado. Se realizó una laparotomía exploradora; Se realizó hemicolectomía izquierda, colostomía terminal y procedimiento de Hartmann, resección del yeyuno afectado y anastomosis terminoterminal. Al noveno día postoperatorio se realiza tomografía abdominal por presencia de picos febriles, que reporta trombosis de arteria renal izquierda y pielonefritis enfisematosa, con presencia de colección pararrenal izquierda. Se realizó nefrectomía izquierda simple. La vigilancia postoperatoria fue satisfactoria durante los siguientes 5 días. El paciente fue dado de alta. Una lesión por empalamiento es una lesión compleja que necesita una atención especial desde el ámbito médico para su correcto manejo. Aunque existe cierta literatura al respecto, alentamos a que se realicen más investigaciones sobre estas lesiones.

Trauma hepático grave con compromiso vascular y fuga biliar. Reporte de dos casos / Severe liver trauma with vascular compromise and biliary leak. Report of two cases

Introducción: El hígado se lesiona con mayor frecuencia en un trauma de abdomen de alta energía, con una incidencia entre 1 % y 8 %. Las lesiones traumáticas de las vías biliares son muy raras. Casos clínicos: Presentamos dos pacientes con trauma hepático grave, y compromiso ex-trahepático vascular y de la vía biliar; y el abordaje quirúrgico para preservar funcional-mente ambos lóbulos: Masculino de 1 año, trauma hepático grado V, lesión incompleta de vena porta derecha, a nivel de la bifurcación y del conducto biliar hepático izquierdo. Se reparó el daño portal y de la vía biliar. Femenina de dos años, trauma cerrado de abdomen, lesión del parénquima de lóbulo derecho del hígado, sección total del conducto hepático izquierdo, y contusión pancreática asociada. En ambos casos se realizó una hepáticoyeyunostomía en Y de Roux y conservación de ambos lóbulos. Conclusión: En los traumas complejos hepáticos que involucran ambos lóbulos, la evolución depende de calidad de la masa residual. La cirugía conservadora con reconstrucciones vasculares y biliares, evita un fallo hepático agudo, permite ganar tiempo hasta la regeneración funcional del parénquima y proteger de una eventual insuficiencia hepática post-operatoria.

Introduction: The liver is more frequently injured in high-energy abdominal trauma, with an incidence between 1% and 8%. Traumatic injuries to the bile ducts are infrequent. Clinical cases: We present two patients with severe liver trauma and extrahepatic vascular and bile duct involvement and the surgical approach to preserve both lobes functionally: 1-year-old male, grade V liver trauma, incomplete injury to the right portal vein, at the level of the bifurca-tion and the left hepatic bile duct. The portal and bile duct damage was repaired. Two-year-old female, blunt abdominal trauma, injury to the parenchyma of the right lobe of the liver, whole section of the left hepatic duct, and associated pancreatic contusion. In both cases, a Roux-en-Y hepatic jejunostomy was performed, and both lobes were preserved. Conclusion: In complex liver trauma involving both lobes, the evolution depends on the quality of the residual mass. Conservative surgery with vascular and biliary reconstructions avoids acute liver failure, allows time to gain until the funct.

Tratamiento mininvasivo de las complicaciones del traumatismo hepático cerrado / Minimally invasive management of blunt hepatic trauma complications

RESUMEN Antecedentes: el manejo no operatorio del traumatismo hepático cerrado es exitoso en el 95% de los pacientes hemodinámicamente normales. Las lesiones de alto grado presentan una tasa de complicaciones de hasta un 14%, y una mortalidad del 27% cuando requieren cirugía abierta. Material y métodos: estudio descriptivo de informe de casos. Resultados: 3 casos con traumatismo hepático de alto grado. "A": manejo no operatorio inicial, lavado laparoscópico por hemoperitoneo sintomático, drenaje percutáneo de absceso hepático, recambio de catéter y CPRE, por fístula biliar persistente. "B": cirugía de control de daño inicial sin hepatectomía, drenaje percutáneo de absceso hepático y posterior recambio. "C": manejo no operatorio inicial, lavado laparoscópico por hemoperitoneo sintomático, posterior drenaje percutáneo de absceso hepático y recambio de drenajes. No presentaron mortalidad. Conclusión: estos casos resumen la utilización de las diferentes modalidades del manejo del traumatismo hepático cerrado y la posibilidad del manejo mininvasivo de las complicaciones.

ABSTRACT Background: Nonoperative management of blunt hepatic trauma is successful in 95% of hemodynamically stable patients. The complication rate of high-grade injuries is 14% and mortality reaches 27% when they require open surgery. Material and methods: We conducted a descriptive study of case reports. Results: Three cases of high-grade hepatic trauma are reported. "A": initial nonoperative management, laparoscopic lavage due to symptomatic hemoperitoneum, percutaneous drainage of liver abscess, catheter replacement and ERCP due to persistent biliary fistula. "B": initial damage control surgery without liver resections, percutaneous drainage of liver abscess and catheter replacement. "C": initial nonoperative management, laparoscopic lavage due to symptomatic hemoperitoneum, percutaneous drainage of liver abscess and catheter replacement. None of the patients died. Conclusion: These cases summarize the use of different management modalities of blunt hepatic trauma and the possibility of minimally invasive management of the complications.

Características clínico quirúrgicas de los pacientes con trauma cerrado de abdomen / Clinical-Surgical Characteristics of Patients with Blunt Abdominal Trauma

Introducción: El traumatismo abdominal cerrado puede provocar lesiones orgánicas graves con hemorragias que demandan un tratamiento quirúrgico emergente y es la principal causa de muertes evitables en todos los grupos de edad. Objetivo: Evaluar las características clínico quirúrgicas de los pacientes con trauma cerrado de abdomen. Métodos: Se realizó un estudio observacional descriptivo y retrospectivo para evaluar el comportamiento del trauma cerrado de abdomen en 81 pacientes atendidos en el Hospital General Provincial Docente "Roberto Rodríguez Fernández" de Morón desde enero del 2014 hasta diciembre de 2019. Resultados: El adulto joven fue el grupo de edad predominante (34,6 por ciento) del sexo masculino (19,8 por ciento), el accidente de tránsito (48,1 por ciento) fue la causa principal. El cuadro hemorrágico (39,5 por ciento) seguidos del cuadro doloroso abdominal (38,3 por ciento) representaron los síntomas clínicos más relevantes. La positividad de los exámenes auxiliares estuvo representada por la ecografía abdominal (74,1 por ciento) seguida de la punción abdominal (9,9 por ciento. Las lesiones hepáticas (27,0 por ciento) seguidas de las esplénicas (19,0 percent) fueron las vísceras macizas más afectadas. El 77,8 por ciento fue intervenido quirúrgicamente y las técnicas quirúrgicas hepáticas fueron las más empleadas para un total de 17 casos (26,9 por ciento). El choque hipovolémico (12,7 por ciento) fue la complicación posoperatoria más encontrada. Se reportó un 12,3 por ciento de fallecidos. Conclusiones: El paciente con trauma cerrado de abdomen debe ser considerado siempre politraumatizado cuyo tratamiento inicial se dirige a la estabilización rápida e identificación de lesiones que amenacen la vida(AU)

Introduction: Blunt abdominal trauma can cause severe organ injury with hemorrhage demanding emergent surgical treatment. It is the leading cause of preventable death among all age groups. Objective: To assess the clinical-surgical characteristics of patients with blunt abdominal trauma. Methods: A descriptive and retrospective observational study was carried out to assess the characteristics of blunt abdominal trauma in 81 patients treated at Roberto Rodríguez Fernández General Provincial Teaching Hospital of Morón from January 2014 to December 2019. Results: Young adults represented the predominant age group (34.6 percent), together with the male sex (19.8 percent). Traffic accident (48.1 percent) was the main cause. Hemorrhagic symptoms (39.5 percent) was the most relevant clinical symptoms, followed by abdominal pain (38.3 percent). Positive results in complementary tests were represented by abdominal ultrasound (74.1 percent), followed by abdominal puncture (9.9 percent). Hepatic lesions (27.0 percent) was the most affected solid viscera, followed by splenic lesions (19.0 percent). 77.8 percent of cases were operated on and hepatic surgical techniques were the most frequently used, accounting for 17 cases (26.9 percent). Hypovolemic shock (12.7 percent) was the most frequent postoperative complication. A death rate of 12.3 percent was reported. Conclusions: The patient with blunt abdominal trauma should always be considered polytraumatized, in which case the initial treatment is aimed at rapid stabilization and identification of life-threatening injuries(AU)

Trauma abdominal penetrante por heridas de arma blanca. Manejo laparoscópico vs convencional. Estudio prospectivo y comparativo / Penetrating abdominal trauma due to stab wounds. Laparoscopic vs conventional management. Prospective and comparative study

La evaluación y el manejo del trauma abdominal ha presentado cambios significativos en los últimos tiempos. La laparoscopia en el trauma abdominal penetrante ha sido de gran utilidad principalmente como método diagnóstico, sin embargo, se debería considerar como herramienta terapéutica.Objetivo: Determinar la eficacia del manejo laparoscópico vs el convencional en el tratamiento de pacientes con trauma abdominal penetrante por heridas de arma blanca.Métodos : Estudio experimental, prospectivo, comparativo. La población de estudio estuvo representada por pacientes con diagnóstico de traumatismo abdominal penetrante por herida de arma blanca que ingresaron a la emergencia de cirugía del Hospital Dr. Miguel Pérez Carreño durante el periodo enero 2019 a julio 2021.Resultados : Fueron incluidos 48 pacientes, 28 pacientes del grupo control y 20 pacientes del grupo experimental. Ambos grupos fueron comparables con respecto a edad y sexo. El índice de severidad del trauma (PATI) fue similar en ambos grupos. Las complicaciones y el tiempo quirúrgico no tuvieron diferencias estadísticamente significativas. Las cirugías negativas representaron el 15 % en el grupo laparoscópico vs 11 % en el abordaje convencional. El porcentaje de conversión fue de 15 %. La estancia hospitalaria fue menor en el grupo laparoscópico 3,25 vs 4,6 días (p = 0,04).Conclusión: La cirugía laparoscópica puede considerarse el abordaje de elección en pacientes hemodinámicamente estables con trauma abdominal penetrante por herida de arma blanca, siendo un método seguro y eficaz, brindando los beneficios propios de la cirugía mínimamente invasiva, con baja tasa de complicaciones y una recuperación más rápida(AU)

The evaluation and management of abdominal trauma have changed significantly in recent times. Laparoscopic approach in penetrating abdominal trauma has been useful as diagnostic method, however, its therapeutic value should be considered. Objective: To determine the efficacy of laparoscopy versus laparotomy approach as treatment in patients with penetrating abdominal trauma caused by stab wounds. Methods: We conducted an experimental, prospective and comparative study. Study population was represented by patients with diagnosis of penetrating abdominal trauma due to stab wounds who were admitted to the emergency room of Dr. Miguel Pérez Carreño Hospital between January 2019 and July 2021.Results : 48 patients were included, 28 in the control group and 20 patients in the experimental group. No differences were found between groups regarding age and sex. The penetrating abdominal trauma index (PATI) was similar in both groups. Differences in complications and surgical time were not statistically significant. Non-therapeutic surgeries represented 15 % in laparoscopic group and 11 % in laparotomy group. The conversion percentage was 15 %. Hospital stay were shorter in laparoscopic group, 3.25 vs 4.6 days (p = 0.04). Conclusion: Laparoscopic surgery can be considered the approach of choice in hemodynamically stable patients with penetrating abdominal trauma due to stab wounds. It is a safe and effective method, providing the benefits of minimally invasive surgery, with a low rate of complications and faster patient recovery(AU)

Ocorrência da laparotomia de urgência e fatores de risco associados à relaparotomia / Ocurrencia de laparotomía de emergencia y factores de riesgo asociados a la relaparotomía / Occurrence of emergency laparotomy and risk factors associated with relaparotomy

A laparotomia consiste no acesso cirúrgico aos órgãos da cavidade abdominal, quando classifica-da como urgente apresenta-se quando há necessidade de se explorar a dimensão de lesões abdominais ou para investigar e tratar patologias desconhecidas. Por vezes, tal procedimento apresenta complicações onde há a necessidade de uma relaparotomia. O objetivo deste estudo foi descrever a ocorrência da laparotomia de urgência e fatores de risco associados à relaparotomia. Trata-se de um estudo retrospectivo, analítico e de caráter quantitativo, realizado em hospital de urgência e emergência do estado de Pernambuco. A amostra foi composta por 120 prontuários. Os resultados apresentaram perfis de risco distintos. Para a laparotomia houve a prevalência do sexo masculino, idade <50 anos, com o etilismo sendo um hábito de vida considerado fator de risco relevante e o desfecho clínico mais comum foi a alta hospitalar. Já no caso da relaparotomia, houve prevalência no sexo feminino, idade >50 anos, sendo a idade elevada considera um fator de risco para complicações, como fatores de risco clínico, o tabagismo e a hipertensão arterial prevaleceram, a classificação do ASA III e IV também se mostrou relevante e o desfecho clínico mais representativo foi o óbito. Em ambos os perfis, a causa inicial se mostrou signifi cativa para a diferença no desfecho clínico dos prontuários analisados. Conhecer a ocorrência da laparotomia de urgência e os fatores de risco para relaparotomias proporciona a equipe multiprofissional dos serviços de saúde um conhecimento prévio para que haja o planejamento adequado da assistência e a implantação de medidas preventivas.

Laparotomy consists of surgical access to the organs of the abdominal cavity, when classified as urgent, it appears when there is a need to explore the dimension of abdominal injuries or to investigate and treat unknown pathologies. Sometimes, this procedure presents complications where there is a need for a relaparotomy. the aim of this study was to describe the occurrence of emergency laparotomy and risk factors associated with relaparotomy. this is a retrospective, analytical and quantitative study carried out in an emergency hospital in the state of Pernambuco. The sample consisted of 120 medical records. The results showed different risk profiles. For laparotomy, there was a prevalence of males, age <50 years, with alcoholism being a life habit considered a relevant risk factor and the most common clinical outcome was hospital discharge. In the case of relaparotomy, there was a prevalence in females, age> 50 years, with high age considered a risk factor for complications, as clinical risk factors, smoking and arterial hypertension prevailed, the classification of ASA III and IV it also proved to be relevant and the most representative clinical outcome was death. In both profiles, the initial cause was significant for the difference in the clinical outcome of the analyzed medical records. Knowing the occurrence of emergency laparotomy and the risk factors for relaparotomy provides the multidisciplinary team of health services with prior knowledge so that there is adequate planning of care and the implementation of preventive measures.

La laparotomía consiste en el acceso quirúrgico a los órganos de la cavidad abdominal, cuando se clasifica como urgente, aparece cuando es necesario explorar la dimensión de las lesiones abdominales o investigar y tratar patologías desconocidas. A veces, este procedimiento presenta complicaciones donde existe la necesidad de una relaparotomía. El objetivo de este estudio fue describir la aparición de laparotomía de emergencia y los factores de riesgo asociados con la relaparotomía. Este es un estudio retrospectivo, analítico y cuantitativo realizado en un hospital de emergencia en el estado de Pernambuco. La muestra consistió en 120 registros médicos. Los resultados mostraron diferentes perfi les de riesgo. Para la laparotomía, hubo una prevalencia de varones, edad <50 años, siendo el alcoholismo un hábito de vida considerado un factor de riesgo relevante y el resultado clínico más común fue el alta hospitalaria. En el caso de la relaparotomía, hubo una prevalencia en las mujeres, edad > 50 años, con la edad alta considerada un factor de riesgo de complicaciones, ya que prevalecieron los factores de riesgo clínico, el tabaquismo y la hipertensión arterial, la clasificación de ASA III y IV también demostró ser relevante y el resultado clínico más representativo fue la muerte. En ambos perfiles, la causa inicial fue significativa para la diferencia en el resultado clínico de los registros medicos analizados. Conocer la aparición de laparotomía de emergencia y los factores de riesgo de la relaparotomía proporciona al equipo multidisciplinario de servicios de salud conocimientos previos para que hay a una planificación adecuada de la atención y la implementación de medidas preventivas.

Ascitis pancreática traumática, manejo conservador: reporte de un caso / Post-traumatic pancreatic ascites, conservative management: a case

Resumen Objetivo: Presentar el caso de un paciente masculino adulto joven, con ascitis pancreática secundaria a lesión del conducto pancreático por trauma abdominal cerrado, tratado con éxito con terapia conservadora. Materiales y Método: Datos e imágenes recopilados de la historia clínica del Hospital Universitario de Santander, previo consentimiento informado. Resultados: Sexo masculino de 21 años con antecedente de trauma abdominal cerrado, quien consulta por distensión, dolor abdominal progresivo y pérdida de peso no cuantificada. Ante sospecha de lesión de conducto pancreático se solicitó pancreatografía por resonancia magnética que evidencia una alteración del segmento proximal del conducto pancreático principal asociado a lesión quística en el borde anterior de la unión de la cabeza con el cuerpo pancreático. Se decidió manejo conservador por 4 semanas con colocación de dren abdominal, reposo intestinal, asociado a nutrición parenteral total y análogos de somatostatina. Discusión: Un 5% del trauma abdominal cerrado puede provocar pancreatitis y fugas en el conducto pancreático. Conclusión: La lesión del conducto pancreático principal debe sospecharse en todos los pacientes con trauma abdominal cerrado. El manejo debe realizarse con una planificación cuidadosa y exhaustiva.

Aim: To present the case of a young adult male patient, with pancreatic ascites secondary to pancreatic duct injury due to blunt abdominal trauma, treated successfully with conservative therapy. Materials and Method: Data and images were obtained from the clinical chart of the "Hospital Universitario de Santander" with prior informed consent. Results: 21-year-old male patient with a blunt abdominal trauma background, who consulted for distension, progressive abdominal pain, and subjective weight loss. Due to suspicion of a pancreatic duct injury, a magnetic resonance cholangiopancreatography was requested, which showed an alteration of the proximal segment of the main pancreatic duct associated with a cystic lesion at the anterior border of the junction between the pancreatic head and body. Treatment consisted of a 4-week conservative therapy with the placement of an abdominal drain, bowel rest, associated with total parenteral nutrition and somatostatin analogs. Discussion: A 5% of blunt abdominal trauma can cause pancreatitis and pancreatic duct leaks. Conclusión: Pancreatic duct injury should be suspected in every patient with blunt abdominal trauma. Management must be done with careful and thorough planning.

Terapia asistida con vacío y estoma flotante (floating stoma): una nueva forma de tratar un absceso periostomal / Vacuum assisted therapy and floating stoma: S new way to treat a periostomal abscess

Resumen Introducción: Los estomas flotantes se definen como un estoma que no está fijado a la piel de la pared abdominal, esta técnica se ha descrito en cirugía para fístulas entero-atmosféricas y de control de daños. Caso Clínico: Presentamos un reporte de caso de manejo de absceso paraostomal en paciente con antecedente de laparotomía por abdomen agudo, por lo que se decide uso de terapia de presión negativa asociada a estoma flotante, demostrando su utilidad en este tipo complejo de pacientes.

Introduction: Floating stomata are defined as a stoma that is not attached to the skin of the abdominal wall, this technique is described in surgery for entero-atmospheric fistulas and damage control. Clinical Case: We present a case report of the management of paraostomal abscess in a patient with a history of laparotomy due to acute abdomen, it was decided to use negative pressure therapy associated with a floating stoma, demonstrating its usefulness in this complex type of patient.

Hernia diafragmática: Un desafío diagnóstico / Diaphragmatic Hernia: A Diagnostic Challenge

Introducción: La hernia diafragmática traumática es una complicación grave del traumatismo abdominal o torácico. Se considera una entidad poco frecuente. El diagnóstico es difícil y, a menudo, puede pasar inadvertido. Objetivo: El propósito de este caso clínico es demostrar la necesidad de sospechar la presencia de hernia diafragmática en los pacientes con trauma toracoabdomial. Presentación del Caso: Paciente de 75 años que sufre accidente de tránsito, con evaluación inicial sin alteraciones clínico-radiológicas, que posteriormente presentan evolución desfavorable con hallazgo radiográfico de una hernia diafragmática traumática. Conclusiones: La hernia diafragmática cuando se presenta constituye un verdadero reto para el diagnóstico por parte del personal médico; pues esta requiere de un alto índice de sospecha y el uso adecuado de las imágenes diagnósticas. Se considera una entidad importante para la evaluación del paciente traumatizado(AU)

Introduction: Traumatic diaphragmatic hernia is a serious complication of abdominal or thoracic trauma. It is considered a rare pathology. The diagnosis is difficult and can often go unnoticed. Objective: The purpose of this clinical case is to demonstrate the need to suspect the presence of diaphragmatic hernia in patients with thoracoabdomial trauma. Case Presentation: Seventy-five-year-old patient who suffers a traffic accident. At initial evaluation no clinical-radiological alterations were observed, but later the patient presented an unfavorable evolution with radiographic finding of a traumatic diaphragmatic hernia. Conclusions: Diaphragmatic hernia, when present, is a real challenge for the diagnosis by the medical staff since it requires a high index of suspicion and an adequate use of diagnostic images. It is considered an important entity in the evaluation of the trauma patient(AU)

Retrospective study of polytrauma patients's medical records that presented abdominal trauma, comperad to abdominal trauma and extra-abdominal injuries

This study sought to retrospectively assess the relationship between intra and extra-abdominal injuries in polytrauma patients undergoing laparotomy at the Regional University Hospital of Maringá between 2017 and 2018.This study was based on 111 electronic medical records from the Brazilian public health system "SUS", admitted to the hospital due to trauma and undergoing laparotomy, comparing two groups: abdominal injury without extra-abdominal injury (WoEI) and abdominal injury with extra-abdominal injury (WiEI).A total of 111 medical records were analyzed, 57 from 2017 and 54 from 2018. Of these 111records, 43 (39%) were trauma victims with only abdominal injuries and 68 (61%) trauma victims with abdominal and extra-abdominalinjuries. Most patients were male (85%), with an average age of 33 years, ranging from 14 to 87 years. In statistical analysis, according to the T-test, there was significance (p > 0.05) between the WoEI and WiEI groups for data collected regarding death rates and hospitalization days. As for the morbidity rate and difference between genders (male and female), there was no statistical significance (p < 0.05).Polytraumapatients are exposed to greater kinetic energy, with more severe conditions and therefore required more in-hospital care.

Aspectos histopatológicos comparativos da pele de orelha e abdômen de cães naturalmente infectados por Leishmania infantum / Comparative histopathological aspects of the ear and abdomen skin of dogs naturally infected by Leishmania infantum

A leishmaniose visceral (LV) representa um importante problema de saúde pública. O cão é considerado o principal reservatório doméstico, pois mesmo quando assintomático pode apresentar carga detectável de Leishmania na pele sadia possuindo capacidade de infectar o vetor. As lesões de pele em cães acometidos por LV têm sido frequentemente observadas, e a pele da orelha tem mostrado uma maior intensidade de alterações inflamatórias, além de uma maior carga parasitária em relação a outros locais analisados. No entanto, as alterações vasculares na derme e possível correlação com o aumento da carga parasitária e disseminação do parasito pela pele ainda não estão completamente estabelecidas. O objetivo deste estudo foi avaliar as alterações inflamatórias e vasculares em pele de orelha e abdômen de cães naturalmente infectados por Leishmania infantum e sua correlação com a carga parasitaria e a sintomatologia clínica. Vinte e seis cães positivos no teste DPP®CVL e ELISA foram incluídos nesse estudo. Após avaliação clínica, os animais foram divididos em grupos: 1- assintomáticos; 2- sintomáticos. Observamos que os sinais clínicos dermatológicos são observados com maior frequência em relação a outros sinais clínicos, sendo a dermatite o sinal clínico dermatológico mais observado. Os fragmentos de pele de orelha mostraram carga parasitária elevada independente da progressão da doença e distribuída de forma mais difusa. Foi observado também maior intensidade de infiltrado inflamatório em relação a pele de abdômen, além de maior reação granulomatosa. A menor quantidade de colágeno foi observada em pele de orelha e se associou com o maior número e distribuição da carga parasitária pelo tecido. Ao analisar as alterações vasculares, em ambos os grupos, a pele da orelha apresentou vasos sanguíneos com maior diâmetro e maior número em relação àqueles da pele de abdômen. Foi possível observar correlação positiva entre o número de amastigotas e o número de vasos presentes na derme, assim como associação entre a presença de amastigotas e intensidade do infiltrado inflamatório. Em conjunto, os dados sugerem uma relação entre as alterações vasculares e a disseminação do parasito pela pele de cães possivelmente impactando no seu papel como reservatório da LV. Além disso, indicam que a pele da orelha se mostrou um sítio interessante para a coleta de amostras clínicas para diagnóstico devido a maior probabilidade de detecção de amastigotas. (AU)

Visceral leishmaniasis (VL) represents a very important public health problem. The dog is considered the main domestic reservoir, because even when asymptomatic it can have a detectable Leishmania load in the healthy skin, being able to infect the vector. Skin lesions in dogs affected by VL have been frequently observed, and the skin of the ear has shown a higher intensity of inflammatory changes, in addition to a higher parasite load in relation to other sites analyzed. However, the vascular changes in the dermis and possible correlation with increased parasite load and parasite spread through the skin are not yet fully established. The aim of this study was to evaluate inflammatory and vascular changes in the skin of the ear and abdomen of dogs naturally infected with Leishmania infantum and their correlation with parasite load and clinical symptoms. Twenty-six dogs positive for DPP®CVL and ELISA were included in this study. After clinical evaluation, the animals were divided into groups: 1- asymptomatic; 2- symptomatic. We observed that dermatological clinical signs are observed more frequently than other clinical signs, with dermatitis being the most observed dermatological clinical signEar skin fragments showed high parasite load independent of disease progression and more diffusely distributed. A greater intensity of inflammatory infiltrate was also observed in relation to the skin of the abdomen, in addition to a greater granulomatous reaction. The lowest amount of collagen was observed in the ear skin and was associated with the highest number and distribution of the parasite load in the tissue. When analyzing the vascular alterations, in both groups, the ear skin presented blood vessels with larger diameter and greater number in relation to those of the abdomen skin. It was possible to observe a positive correlation between the number of amastigotes and the number of vessels present in the dermis, as well as an association between the presence of amastigotes and the intensity of the inflammatory infiltrate. Taken together, the data suggest a relationship between vascular changes and the spread of the parasite through the skin of dogs possibly impacting on their role as a VL reservoir. Furthermore, they indicate that the skin of the ear proved to be an interesting site for collecting clinical samples for diagnosis due to the higher probability of amastigotes detection. (AU)

Achados tomográficos nos traumas abdominais contusos e perfil dos pacientes / Tomographic findings in contune abdominal trauma and patient profile

O trauma é a 5ª. causa de morte no mundo e, na população com menos de 40 anos, é a maior causa de óbitos. O abdome é região frequentemente lesada e requer tratamento cirúrgico com frequência. Em se tratando de trauma contuso, exames de imagem oferecem diagnóstico mais acurado conduzindo tratamento mais adequado. O objetivo deste estudo foi avaliar a relação dos achados tomográficos, do exame físico e a prevalência das lesões. Foram selecionados 39 politraumatizados e vítimas de trauma abdominal contuso, através de um estudo prospectivo. Foram comparados exame físico e o achado tomográfico. Em conclusão, mostrou-se que a avaliação clínica isoladamente pode fazer com que lesões passem desapercebidas; a tomografia computadorizada teve boa sensibilidade e especificidade devendo ser realizada para diagnosticar e melhor guiar a terapêutica.

Trauma is the 5th cause of death in the world and, in the population under 40 years old, it is the biggest cause of death. The abdomen is a frequently injured region and often requires surgical treatment. In the case of blunt trauma, imaging tests offer a more accurate diagnosis leading to more appropriate treatment. The aim of this study was to evaluate the relationship between tomographic and physical examination findings and the prevalence of lesions. Thirty-nine polytraumatized and victims of blunt abdominal trauma were selected through a prospective study. Physical examination and tomographic findings were compared. In conclusion, it has been shown that clinical assessment alone can make lesions go unnoticed; computed tomography had good sensitivity and specificity and should be performed to diagnose and better guide therapy.

Non-operative management of blunt splenic trauma: evolution, results and controversies / Tratamento não operatório do trauma esplênico: evolução, resultados e controvérsias

ABSTRACT The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

RESUMO O baço é um dos órgãos mais frequentemente afetados no trauma abdominal contuso. Desde os trabalhos de Upadhyaya, o tratamento do trauma esplênico vem sofrendo importantes modificações. Atualmente, é consenso que todo trauma esplênico que se apresenta com estabilidade hemodinâmica pode ser tratado inicialmente de forma não operatória, desde que o serviço possua estrutura adequada e o paciente não apresente outras condições que indiquem exploração da cavidade abdominal. Entretanto, vários tópicos permanecem controversos no que diz respeito ao tratamento não operatório (TNO) do trauma esplênico. A angioembolização esplênica é uma ferramenta de grande auxílio no TNO, porém não há consenso sobre suas indicações precisas. Não há uma definição na literatura a respeito da forma como o TNO deve ser conduzido, tampouco a respeito da periodicidade do controle hematimétrico, do limiar de transfusão que define falha do TNO, de quando iniciar a profilaxia contra tromboembolismo venoso, da necessidade de exames de imagem de controle, do período de repouso no leito, e de quando é seguro indicar alta hospitalar. O objetivo desta revisão é analisar de forma crítica a literatura a respeito desse tema, expondo o estado da arte no TNO do trauma esplênico.

Impacto de la infección por SARS-CoV-2 (COVID-19) en el tratamiento de una lesión duodenal por arma de fuego / Impact of SARS-CoV-2 infection (COVID-19) in the treatment of duodenal gunshot injury

RESUMEN Se presenta el caso clínico de un paciente con traumatismo abdominal por herida de arma de fuego (HAF). En otra institución se realizó cirugía de exclusión pilórica y hepatorrafia por lesión hepatoduo denal. Fue derivado a nuestra institución a las 12 horas posoperatorias. Intercurre en el posoperatorio con neumonía grave por COVID-19 y complicaciones de su cirugía ini cial. La presentación severa de la enfermedad nos inclina por el manejo no operatorio. La utilización de drenajes percutáneos permitió el manejo de colecciones evitando una cirugía mayor inicial. La recuperación pulmonar facilitó la cirugía definitiva. La neumonía severa por COVID-19 en un paciente con lesión duodenal grave por HAF condiciona la toma de decisiones.

ABSTRACT We report the case of a patient with an abdominal gunshot trauma with liver and duodenal injury who underwent pyloric exclusion and liver repair in another institution. The patient was transferred to our institution 12 hours after surgery. During hospitalization, severe pneumonia due to COVID-19 and complications of the initial surgery developed. Non-surgical management was decided due to the severity of the disease. Percutaneous drainage allowed for the management of the collections avoiding a major initial surgery. Once he recovered from the pneumonia, the definite surgery was performed. Severe COVID-19 pneumonia in a patient with serious duodenal shotgun injury is a determining factor for decision-making of treatment options.

Os preditores da mortalidade em esplenectomias não traumáticas / The predictors of mortality in non-traumatic splenectomies

ABSTRACT BACKGROUND: There are quite a few studies examining prognostic factors in non-traumatic splenectomies compared to traumatic ones. OBJECTIVE: This study aimed to evaluate the predictors of mortality in patients who underwent splenectomy for non-traumatic spleen diseases. METHODS: Medical records of the patients, who had undergone total splenectomy for non-traumatic spleen diseases at a tertiary center between January 2009 and December 2019, were retrospectively reviewed. Exclusion criteria included patients younger than 18 years of age, partial splenectomies, splenectomies applied to facilitate surgery for malignancy on contiguous organs, and splenectomies performed during liver transplantation. Iatrogenic splenic injuries were regarded as trauma and these cases were also excluded. RESULTS: The current study included 98 patients. Nine (9.2%) patients died. In univariate analysis, age, the presence of hematological neoplasia, hematocrit, hemoglobin, white blood cell counts, neutrophil-to-lymphocyte ratio, indications for splenectomy, application of emergency surgery, surgical technique, and transfusion of blood components were all significantly associated with mortality. In multivariate analysis, the presence of hematological malignancy [P=0.072; OR=7.17; (CI: 0.386-61.56)], the application of emergency surgery [P=0.035; OR=8.33; (CI: 1.165-59.595)] and leukocytosis [P=0.057; OR=1.136; (CI: 0.996-1.296)] were found to be positively associated with mortality. CONCLUSION: Hematologic neoplasia, emergency surgery, and leukocytosis were the independent predictors of mortality in patients, who were operated on for non-traumatic spleen diseases. A thorough preoperative evaluation, early therapeutic intervention, and advanced surgical techniques are important and can serve to minimize complications and mortality in case of inevitable splenectomy. Immunological research can provide new therapeutic opportunities that may impact positively on patients by minimizing morbidity and mortality.

RESUMO CONTEXTO: Há alguns estudos que examinam fatores prognósticos em esplenectomias não traumáticas em comparação com os traumáticos. OBJETIVO: Este estudo teve como objetivo avaliar os preditores de mortalidade em pacientes submetidos à esplenectomia para doenças do baço não traumático. MÉTODOS: Os prontuários dos pacientes, submetidos à esplenectomia total não traumática para doenças do baço em um centro terciário entre janeiro de 2009 e dezembro de 2019, foram revisados retrospectivamente. Os critérios de exclusão incluíram pacientes menores de 18 anos, esplenectomias parciais, esplenectomias aplicadas para facilitar a cirurgia para a malignidade em órgãos contíguos e esplenectomias realizadas durante o transplante hepático. As lesões esplênicas iatrogênicas foram consideradas trauma e esses casos também foram excluídos. RESULTADOS: O presente estudo incluiu 98 pacientes. Nove (9,2%) pacientes morreram. Na análise univariada, idade, presença de neoplasia hematológica, hematócrito, hemoglobina, contagem de glóbulos brancos, razão entre neutrófilos-linfócitos, indicações de esplenectomia, aplicação de cirurgia de emergência, técnica cirúrgica e transfusão de componentes sanguíneos foram significativamente associadas à mortalidade. Na análise multivariada, a presença de malignidade hematológica [P=0,072; OR=7,17; (IC: 0,386-61,56)], aplicação de cirurgia de emergência [P=0,035; OR=8,33; (IC: 1,165-59,595)] e leucocitose [P=0,057; OR=1,136; (IC: 0,996-1,296)] verificou-se que estão positivamente associados à mortalidade. CONCLUSÃO: Neoplasia hematológica, cirurgia de emergência e leucocitose foram os preditores independentes da mortalidade em pacientes, operados por doenças não traumáticas do baço. Uma avaliação pré-operatória minuciosa, intervenção terapêutica precoce e técnicas cirúrgicas avançadas são importantes e podem servir para minimizar complicações e mortalidade em caso de inevitável esplenectomia. Pesquisas imunológicas podem fornecer novas oportunidades terapêuticas que podem impactar positivamente nos pacientes, minimizando a morbidade e a mortalidade.