Herida penetrante cardíaca / Cardiac penetrating wound

Las primeras descripciones de una lesión cardiaca se remontan al papiro de Edwin Smith alrededor del 3000 AC. Hasta el siglo IX, las heridas penetrantes cardiacas eran consideradas intratables y mortales. Fue en 1896, cuando se reportó la primera reparación cardiaca exitosa. Aunque la mortalidad ha disminuido con el paso del tiempo, una herida penetrante al corazón sigue teniendo un grave pronóstico y es causa importante de morbilidad y mortalidad en pacientes de trauma. En la actualidad, cada vez se ven con más frecuencia las heridas penetrantes cardiacas por arma de fuego, lo que indudablemente ensombrece aún más el pronóstico de estas lesiones, por lo que se torna de vital importancia para el cirujano que trabaja en una Unidad de Emergencia, conocer con exactitud los mecanismos fisiopatológicos que se ven involucrados en este tipo de situaciones, además de todas las complicaciones que pueden ocurrir al intentar reparar una herida penetrante cardiaca. Este artículo pretende dar una visión precisa, clara y actual del manejo de un paciente con una herida penetrante cardiaca.

Nódulo pulmonar solitario: desafío diagnóstico y terapéutico / Solitary pulmonary nodule: a challenge in diagnosis and treatment

El concepto de nódulo pulmonar solitario (NPS) corresponde a una imagen radiológica aumentada de densidad, en general esférica, de bordes bien delimitados, que mide menos de 3cm de diámetro.El NPS ha sido siempre una situación de difícil manejo, que requiere de un enfoque ordenado y especializado. Es por esto, que la aproximación diagnóstica en un paciente con NPS debe basarse en una estimación de la probabilidad de tener cáncer, de esta forma, cuando la posibilidad de cáncer sea baja, el nódulo puede ser seguido por medio de tomografía computada de alta resolución cada tres meses el primer año y cada seis el segundo. En caso de alta sospecha de cáncer, la resección quirúrgica es justificada, idealmente mediante videotoracoscopía. Para pacientes con nódulos indeterminados, puede utilizarse el PET para determinar el riesgo de cáncer. A raíz de los múltiples avances de la medicina y los nuevos métodos diagnósticos disponibles hoy en día, creemos importante revisar este tema entregando herramientas actuales y concretas para el estudio de un paciente con NPS.

Shunt atricova A propósito de dos casos: Report of two cases / Atriocaval shunt

The mortality of grade V and VI liver trauma fluctuates between 30percent and 70percent. The atriocaval shunt, described by Shrock et al, in 1968, is a therapeutic option that, after being installed, allows to repair the suprahepatic veins and retrohepatic cava in a bloodless surgical field. Its use requires an experienced and skilled surgeon to obtain survival rates similar to those obtained with other methods. We report two male patients of 17 and 18 years old treated successfully with this technique after suffering a blunt and a penetrating liver trauma by a shotgun, respectively.

Toracotomía en la sala de reanimación / Thoracotomy in the resuscitation room

Desde su introducción en la década de los sesenta la toracotomía de urgencia o en sala de reanimación se ha extendido en forma considerable a lo largo del mundo, tanto así que forma parte de los protocolos de reanimación cardiopulmonar de todos los centros de trauma nivel I de EE.UU. Dado los últimos avances logrados en atención prehospitalaria cada día más y más pacientes ingresan a las unidades de emergencia en condiciones vitales extremas, por lo que se debe aplicar esta técnica como último intento por salvar la vida del enfermo. Sin embargo, es un procedimiento que debe ser llevado a cabo por cirujanos experimentados, sobre todo en el manejo de lesiones cardiotorácicas penetrantes dada su alta morbilidad y mortalidad. Por otra parte, debe tenerse en cuenta el elevado costo de este procedimiento y el peligro potencial de amplia exposición a vectores infectocontagiosos. Dentro de este procedimiento caben todas las toracotomías realizadas previo al ingreso a pabellón, siendo lo último preferible si las condiciones del enfermo lo permiten. En Chile su practica es limitada y básicamente está dada por la experiencia de la Asistencia Pública de Santiago. Se analiza la literatura existente y se explica la técnica quirúrgica.

Fístulas arteriovenosas (FAV): período 1990-1999, Hospital Clínico Regional de Valdivia / Arteriovenous fistulas: period 1990-1999, Regional Clinical Hospital of Valdivia

Introducción: Desde la introducción de la hemodiálisis por Kolff en 1944, se abre un nuevo camino para los enfermos renales crónicos, sin embargo, persistía un problema sin resolver: un acceso arterial y venoso confiable que Brescia resuelve en 1966, con la introducción de la fístula arteriovenosa radiocefálica, asegurando accesos vasculares expeditos, duraderos y eficientes en relación con el territorio vascular intervenido. Material y Método: Se analizan en forma retrospectiva, las fichas clínicas de 166 pacientes, 101 (60,84 por ciento) hombres y 65 (39,15 por ciento) mujeres, a quienes se les realizó una FAV en el período comprendido entre 01/01/1990 y 31/12/1999, con técnica estandarizada utilizando lidocaína 2 por ciento como anestésico local, anastomosis término-lateral de vena-arteria, arteriotomía en longitud 2,5 veces el diámetro de la arteria y profilaxis con Cloxacilina 1 g ev 30 minutos preoperatorio completando 24 horas con tratamiento oral (500 mg c/6 horas). Resultados: El tiempo medio de enfermedad fue de 7 años fluctuando entre 1 y 30. En 95 por ciento de los casos (158 pacientes), se realizó FAV radiocefálica, localización más frecuente muñeca izquierda en 98 casos (59,63 por ciento) sguida de la derecha en 60 casos (36,14 por ciento), las 8 restantes localizaciones se deben a la anatomía del paciente. Complicaciones técnicas hubo en 36 casos; en 22 casos (13,25 por ciento) fibrosis del territorio venoso. Hubo complicaciones en 35 pacientes, siendo la más frecuente la trombosis en 19 casos (11,44 por ciento). Tiempo medio de maduración de 1 mes fluctuando entre 5 días y 3 meses. Treinta y seis pacientes requirieron nueva FAV y 40 recibieron transplante renal. Duración media de la FAV fue de 4 años fluctuando entre 20 días y 5 años. Discusión: A lo largo del tiempo la técnica descrita por Brescia con trombosis y estenosis. En nuestra serie los casos en que se perdió la FAV, exceptuando aquellos por condiciones propias de los pacientes, se deben a mal manejo de los sitios de punción y poco tiempo de maduración, en todos en los que duró menos de un mes hubo trombosis o estenosis. Si logramos cambiar estos conceptos en nuestro medio optimizaremos la sobrevida de la FAV sin tener que someter a los pacientes a procedimientos seriados, que finalmente conducen al rechazo.

Emergency carotid thromboendarterectomy: safe and effective.

Whether to perform emergency carotid thromboendarterectomy (CTEA) in the presence of crescendo transient ischemic attacks or stroke-in-evolution is controversial, with the operative mortality in some reports exceeding 20% and improvement in neurologic deficit of less than 40% in others. Our anecdotal experience with emergency CTEA for acute, persistent, or crescendo neurologic deficit had been strikingly better than published reports. Accordingly, we carried out a restrospective comparison of 43 such patients undergoing emergency CTEA with 237 patients concurrently undergoing elective CTEA for conventional indications. A standard protocol followed in emergency CTEA patients included carotid Doppler ultrasonography, computed cerebral tomography (CT), four-vessel cerebral arteriography, and intravenous heparin. Exclusions from emergency CTEA included coma or cerebral CT scan evidence for either hemorrhagic or ischemic infarction with edema. Operative techniques included standard carotid endarterectomy with Dacron patch or direct suture, eversion endarterectomy, or shortening resection. No mortality or central neurologic complications resulted among the 43 emergency CTEA patients, in comparison to no deaths and one temporary hemiparesis (0.4% central neurologic morbidity) in the 237 elective CTEA patients. Our results suggest that in the absence of coma or cerebral CT scan evidence for an unstable blood-brain barrier, emergency carotid reconstruction can be performed safely and with excellent outcome notwithstanding the magnitude and severity of the acute preoperative neurologic deficit.

[MR angiography of the lower extremities with an automatic table translation (Mobitrak) compared to i.a. DSA]. / MR-Angiographie der unteren Extremitäten mit automatischer Tischverschiebung ("MobiTrak") im Vergleich zur i.a. DSA.

PURPOSE: Comparison of the diagnostic information obtained by MRA using a moving bed ("MobiTrak") with i.a.DSA for angiography of the lower extremities. MATERIALS AND METHODS: In 20 patients, i.a.DSA and MRA were performed within a few days. The image quality and diagnostic information were evaluated by two radiologists and two surgeons. RESULTS: The radiologists assessed the quality of MRA higher for 18%, for 79% image quality was equal, for 3% the quality was graded as lower in comparison to i.a.DSA. The surgeons found the quality of MRA higher for 16%, equal for 75% and lower for 9%. In all cases, MRA was sufficient for planning of further treatment. CONCLUSIONS: For examinations of the arterial vessels of the lower extremities, MRA with a moving bed ("MobiTrak") can be used instead of i.a.DSA. The diagnostic information from MRA is sufficient for planning the further treatment. The advantages of MRA (no radiation, no i.a. puncture, no contrast medium with iodine) will lead to an increasing application of this method.

[Pancreas carcinoid with extensive liver metastasis--simultaneous excision]. / "Pankreascarcinoid" mit ausgedehnter Lebermetastasierung--simultane Exstirpation.

This case report describes an unusually large islet cell tumour of the pancreas presenting clinically with extensive metastases in the liver. The patient involved was a 55-year-old woman. The leading symptom was severe, hardly tractable diarrhoea. Histological examination including immunohistochemistry and measurements of the proliferation index revealed a probable malignant Vipoma of low grade. It was treated by simultaneous R0 resection of the tumour masses; the postoperative course was unremarkable. This outcome is seen as a strong argument in favour of a radical surgical approach even if there is significant metastatic disease in the liver. The advantage of intraoperative ultrasound is discussed along with aspects of tumour classification and alternative therapeutic modalities.

[Results of modern osteosynthesis procedures in fractures of the radial head--are conservative therapy, bone pin osteosynthesis or primary resection still allowed?]. / Ergebnisse moderner Osteosyntheseverfahren bei Radiusköpfchenfrakturen--Sind konservative Therapie, Spickdrahtosteosynthesen oder primäre Resektionen noch erlaubt?

In a retrospective study, we evaluated the outcome of 38 patients who underwent open reduction internal fixation for displaced radial head fractures. We used resorbable material, as well as titanium implants which need no hardware removal. Our results were 84% good, 6% satisfying and 10% unsatisfying. The latter were due to more severe damage to the elbow joint.

Extended uses for the Herbert/Whipple screw: six case reports out of 35 illustrating technique.

We have used 6.5-mm and 4.5-mm Herbert/Whipple screws in our Trauma Center since 1991. This double-threaded headless device is used primarily in the scaphoid to manage fractures and delayed unions, but can be used successfully to fixate other fractures at diverse sites. In reviewing our experience, we will discuss several characteristics of this screw. These include advantages of the screw, such as generation of only minor soft-tissue trauma in areas of poor soft-tissue coverage or for transcartilaginous fixation, as well as its disadvantages, such as weak interfragmentary compression and low pullout resistance. Case reports are presented to illustrate applications of this device in the upper extremity (fractures of the humeral neck, the articular surface of the shoulder blade, and pseudarthrosis of the olecranon) and in the lower extremity (fractures of the talar neck, the medial malleolus, and Volkmann's triangle).

[The effect of thoracic epidural anesthesia on the pathophysiology of the eventration syndrome]. / Einfluss der thorakalen Epiduralanästhesie auf die Pathophysiologie des Eventrationssyndroms.

Abdominal mesenteric traction (MT) results in decreased mean arterial pressure (MAP), systemic vascular resistance (SVR) and increased cardiac output (CO). This response is induced by a considerable release of prostacyclin (PGI2). Precipitous falls in systemic arterial pressure related to central and/or autonomic nervous reflex arcs also have been described during operations on the upper abdominal viscera. Those hypotensive responses to visceral traction appear to be transmitted along afferent fibres contained within the splanchnic nerves. We investigated the influence of supplementary thoracic epidural anaesthesia on mesenteric traction response during major abdominal surgery. METHODS. With the approval of the Human Investigation Review Board we studied 40 patients scheduled for major abdominal surgery (infrarenal aortic, gastrointestinal and pancreatic surgery) according to a prospective, randomized double-blinded protocol. Patients were randomized to two different anaesthetic regimens. Patients in group 1 received general anaesthesia (GA n = 20) with 0.1-0.15 mg/kg midazolam and 10 micrograms/kg fentanyl prior to skin incision. Maintenance included 65% nitric oxide in oxygen and 0.1 mg increments of fentanyl as required. Group 2 patients (EA n = 20) underwent a combined technique of dose-reduced general anaesthesia and supplementary continuous, thoracic epidural anaesthesia (bupivacaine 0.25%, sensory blockade T4 to L1-3). In both anaesthesia groups ibuprofen (400 mg i.v.) or a placebo equivalent was administered 15 min before the induction of anaesthesia. MT was applied in a uniform fashion. Baseline values preceded the incision of the peritoneum. Further assessments followed 5, 15 and 30 min after MT. The plasma concentrations of 6-keto-PGF1 alpha (stable metabolite of PGI2), TXB2 (stable metabolite of thromboxane), PGF2 alpha, KH2-PGF2 alpha (stable metabolite of PGF2 alpha) were determined by radioimmunoassay. At all assessments we recorded systolic and diastolic blood pressure, heart rate and measured arterial blood gases. Statistical analyses were performed using three-factor ANOVA for repeated measurements after log(x) transformation. A P-value of less than 0.05 was considered significant when the Bonferroni-Holm adjustment was applied. RESULTS. Patients with supplementary epidural anaesthesia demonstrated lower systolic (P = 0.0001) and diastolic (P = 0.006) blood pressure than those in the GA group. Nevertheless, in untreated patients in the EA and GA group there was a significant decrease of about 20-30% in systolic and diastolic blood pressure (P = 0.0001) after mesenteric traction. Irrespective of the anaesthetic procedure, paO2 (P = 0.0001) decreased after mesenteric traction in the placebo group. The control patients in the GA group exhibited a more pronounced increase in heart rate after MT. After traction on the mesentery a significant 20- to 30-fold increase in 6-keto-PGF1 alpha plasma concentrations occurred in the placebo group: GA group 1950/58 (5 min), 1574/59 (15 min) 858/66 (30 min) ng/l, P < 0.0001; EA group: 2002/106 (5 min), 2955/107 (15 min) 1807/70 (30 min) ng/l, P < 0.0001, for placebo vs ibuprofen. There was no statistically significant difference between the two anaesthetic procedures used. In ibuprofen-pretreated patients haemodynamics and paO2 values were stable, while 6-keto-PGF1 alpha plasma concentrations remained within the normal range. CONCLUSION. Our data clearly indicate that the mesenteric traction response consists in relevant haemodynamic alterations and a significant decrease of paO2. Stable haemodynamics and paO2 following cyclooxygenase inhibition signify an action mediated by prostacyclin. Deafferentation of the splanchnic nerves by supplementary thoracic epidural anaesthesia did not influence either prostacyclin release or the decrease in blood pressure and paO2 after traction on the mesentery root...

Heridas penetrantes torácicas / Thoracic penetrating wounds

Analizamos 190 pacientes con heridas penetrantes torácicas, de las cuales el 92 por ciento fue por arma blanca y el 8 por ciento por herida a bala. El 55 por ciento presentó hemotórax, el 22 por ciento neumotórax y el 22 por ciento hemoneumotórax. El 82 por ciento se trataron con pleurocentesis y/o pleurotomía, el 8 por ciento requirió toracotomía de urgencia y en un 10 por ciento se efectuó toracotomía de aseo. Nuestra serie no presentó mortalidad y la morbilidad de un 6 por ciento corresponde fundamentalmente a infecciones y atelectasias pulmonares

Tratamiento quirúrgico de las várices esenciales / Surgical treatment of essentials varices

Entre 1985 y 1989, en el Servicio e Instituto de Cirugía del Hospital Base de Valdivia, se operaron 256 pacientes portadores de várices esenciales de acuerdo a un protocolo de evaluación y tratamiento. Todos los pacientes fueron estudiados con pruebas funcionales, estudio velocimétrico Doppler y flebografía en aquellos en que existió sospecha que eran portadores de várices secundarias. Los enfermos se operaron con una técnica quirúrgica estandarizada, que se analiza en detalle la cual fue practicada por el mismo equipo quirúrgico. Las complicaciones postoperatorias fueron escasas y de poca importancia: 23 infecciones de heridas distales, 2 hemorragias menores y 14 cefaleas postrraquídea. La recidiva a 5 años fue de 2,7 por ciento . Se discuten y comenta la cirugía conservadora de safena interna. Se concluye que esta patología afecta a un número importante de la población y conlleva un alto índice de incapacidad. Un adecuado manejo preoperatorio y una técnica quirúrgica normada permiten reducir significativamente el porcentaje de complicaciones y evitan secuelas funcionales subsecuentes

Técnica quirúrgica: drenajes torácicos / Surgical technic: thoracic drenage

El empleo adecuado de la toracocostomía con sonda produce como resultado el drenaje de aire y/o líquidos acumulados en la cavidad pleural y contribuye a la ocupación completa de esta cavidad por el pulmón, con lo cual disminuye el número de complicaiones pleuropulmonares subsecuentes. Además, constituye un método de vigilancia continua de este espacio, mediante la cuantificación de aire y/o líquidos que se extraen. En este artículo explicamos en forma simple la utilización de los tubos de drenaje (drenes) que con mayor frecuencia se usan en patología pleuropulmonar. Sus indicaciones, instalación, manejo, tipo de tubos y frascos, complicaciones y momento de retiro serán los tópicos a tratar

[Risk in elective cholecystectomy]. / Das Risiko der elektiven Cholezystektomie.

From 3/1982 to 12/1989 773 patient underwent an elective Cholezystectomy at the Surgical University Hospital of Ulm. In 87% of cases the indication was a symptomatic cholelithiasis, the mean age being 55.4 years for females and 56.6 years for males. Intraoperative complications were rare (2.8%) and of a technical nature. Postoperative morbidity was 15.2%. General disturbances occurred in 10.3% and were age-depended. Local postoperative problems (4.9%) did not show this age-dependent distribution. Residual stones were detected in 0.8% of cases; they were removed operatively or endoscopically or crushed by shock waves. 1.3% of patients had to be re-operated. In the age group under 70 years as well as over 70 years lethality was 0%. In 9 cases (1.16%) a gallbladder carcinoma was found incidentally during the operation. We think that elective cholecystectomy is a safe therapeutic procedure in gallbladder stone disease, which also considers the association of chronic cholelithiasis and gallbladder carcinoma.

[Colorectal invagination in adults following removal of a sigmoid polyp]. / Kolorektale Invagination beim Erwachsenen nach Entfernung eines Sigmapolypen.

A unusual case of colorectal intussusception after transanal surgery of a polyp of the sigmoid colon is presented. Clinical Signs consisted of transanal bleeding and mucous diarrhoe. The diagnosis was established after an enema with water-soluble contrast media and computed tomography of the pelvis. The radiological appearance was similar to that of intussusception at other sites of the large bowel: The enema showed a sharply outlined filling defect whereas CT demonstrated a target-like intraluminal mass.

[Cholecystectomy--the gold standard of therapy]. / Die Cholecystektomie--Der goldene Therapiestandard.

Elective CCE is still the treatment of choice for more than 80% of patients with gallstone disease. Surgery is indicated for biliary symptoms along with sonographic or radiographic evidence of gallstones and/or pathology of the gallbladder wall. Non-operative procedures are limited to patients with open cystic duct, preserved contractivity of the gallbladder and non-calcified stones. Mortality of elective cholecystectomy in patients less than 70 years today is 0. Emergency cholecystectomy and old age (greater than 70) are the only mortality risk factors amounting up to 4%. Recurrent surgery is necessary in less than 1% of the patients, conservatively treated postoperative morbidity less than 5%. Cholecystectomy still remains the only method, by which immediate stone release is achieved and long term medication avoided.

[Thromboxane A2 and granulocyte elastase after severe trauma--relationship to complications and survival rates]. / Thromboxan-A2 und Granulozyten-Elastase nach schwerem Trauma--Beziehungen zu Verlaufskomplikationen und Uberlebensraten.

Of 64 polytraumatized patients with a mean injury severity score of 33.1, 42 showed marked systemic release of thromboxane B2 and granulocyte elastase during the initial 18 hours after trauma, reaching peak arterial levels of greater than 1,000 pg/ml and ng/ml, respectively. If those patients ("responders": plasma TXB2 greater than 250 pg/ml) were compared with the remaining 22 ("non-responders": TXB2 less than 250 pg/ml) the following became obvious: "Late" mortality (greater than 3 d) was 31% in responders, which is significantly higher than in non-responders (9%). No correlation was observed between "early" mortality (less than 3 d) and mediator release. There was no difference in the incidence of the adult respiratory distress syndrome (ARDS) (38% versus 32%) or the late sepsis syndrome (17% versus 18%) between responders and non-responders. Morbidity, however, differed markedly in that ARDS in responders was associated with significantly higher elastase levels, a higher mortality and 10 times higher incidence of sepsis as compared to responders without ARDS. ARDS in non-responders, by contrast, did not change elastase maxima or the mortality rate as compared to non-responders without ARDS. It is concluded that TXB2 is not a predictor of posttraumatic ARDS, but is related to a complicated course, in particular to sepsis and mortality. Elastase with high probability predicts ARDS and/or the late sepsis syndrome. Simultaneous determination of TXB2 further enhances the predictive value of elastase.

Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results.

In 128 patients with severe chronic pancreatitis and inflammatory enlargement of the head of the pancreas, a duodenum-preserving resection of the pancreatic head was performed. Median post-operative hospitalization was 15.5 days, and the frequency of reoperation was 5.5%. One patient died during the early post-operative phase, and hospital mortality amounted to 0.8%. After a median follow-up period of 3.6 years (range of 7 months to 16 years), six of 127 patients died (late mortality of 4.7%). Seventy-seven per cent of the patients were completely free of abdominal pain, 67% returned to their former occupations. During the late follow-up period, the glucose metabolism was unchanged in 80.7% of the patients, in 13.7% it deteriorated, and in 5.5% it improved permanently; 80% of the patients experienced a marked increase in weight averaging 8.7 kg. Compared with the Whipple procedure, the duodenum-preserving resection of the head of the pancreas spares the patient with chronic pancreatitis a gastrectomy, duodenectomy, and resection of the extrahepatic biliary ducts. In terms of a subtotal resection, the limited operative intervention at the head of the pancreas and the preservation of the duodenum explain the low early and late postoperative morbidity and mortality.

[Treatment of infection in intensive care patients]. / Behandlung der Sepsis bei Intensivpatienten.

A basic prerequisite of successful treatment of sepsis in intensive care patients is early recognition. Aside from the classic clinical signs of infection, minute changes in volume demand, respiratory need, kidney function and cardiovascular regulation may indicate a septic complication. The surgical/mech. elimination of septic foci is still the paramount therapeutic principle. Volume and respiratory therapy, hemofiltration, cardiovascular and antibiotic medication may add to the standard procedure of intensive care. Contact site inhibitors, mediator antagonists, and antibodies targeted against endotoxin, bacteria or leukocyte surface antigens are either still controversial or undergoing preclinical evaluation.