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.

Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis.

AIM: Vaginal delivery is a well-known risk factor for pelvic floor muscle (PFM) injuries, mainly when associated to prolonged labor, instrumental birth and perineal trauma such as episiotomy and perineal tears. The purpose of this meta-analysis was to test the hypothesis that episiotomy and severe perineal tear may increase the risk of pelvic floor damage. METHODS: We performed a systematic literature search through electronic databases including MEDLINE via PubMed, LILACS via BVS, Embase via Elsevier and Cochrane Library up to January 2019. We included articles that reported as outcome one or more morphological aspects of the PFM evaluated by ultrasonography in primiparous women three to 24 months postpartum. This review is registered in the PROSPERO database (registration number: CRD42017075750). RESULTS: the final selection was composed of 18 articles for the systematic review, and 10 for the meta-analysis. Women with levator ani muscle (LAM) avulsion were 1.77 times more likely to have undergone episiotomy (OR = 1.77, CI 95% 1.25-2.51, five trials), 4.31 times more likely to have severe perineal tear (OR = 4.31, CI 95% 2.34-7.91, two trials). Women with defects in the anal sphincters were 2.82 times more likely to have suffered severe perineal tear (OR = 2.82, 95% CI 1.71-4.67, three trials). CONCLUSIONS: Both episiotomy and severe perineal tear are risk factors for LAM avulsion and anal sphincter injury, and this can be useful for identifying women who are at greater risk of developing PFM dysfunctions.

Splenic Rupture and Liver Laceration in an Adolescent With Autism Spectrum Disorder.

We report a case of a 16-year-old adolescent boy with autism who presented to the pediatric emergency department after falling from a standing position, with a relatively benign examination, who was found to have significant hemoperitoneum on the focused assessment with sonography in trauma examination.

Ultrasound biomicroscopy and claudication test for in vivo follow-up of muscle repair enhancement based on platelet-rich plasma therapy in a rat model of gastrocnemius laceration.

PURPOSE: To track the regeneration process of lateral gastrocnemius due to a muscle laceration in rats, and to treatment with plateletrich plasma (PRP). METHODS: Ultrasound (40 MHz) images were used for measuring pennation angle (PA), muscle thickness (MT) and mean pixel intensity, along with claudication scores, of treated (PRPG) and non-treated (NTG) groups of rats. RESULTS: NTG showed a PA increase for the non-injured leg (p<0.05) and a tendency of MT to increase, whereas for PRPG there were no differences. There was a progressive reduction of the claudication score for the PRPG group throughout the entire period, with an immediate difference after seven days (p<0.05), whereas the NTG had a significant reduction only at day 28 (p<0.05). CONCLUSION: It was observed a compensatory hypertrophic response due to the overload condition imposed to healthy leg for NTG that did not occur in PRPG, suggesting an accelerated repair process of the injured leg due to treatment, anticipating its use.

Ultrasound biomicroscopy and claudication test for in vivo follow-up of muscle repair enhancement based on platelet-rich plasma therapy in a rat model of gastrocnemius laceration

PURPOSE: To track the regeneration process of lateral gastrocnemius due to a muscle laceration in rats, and to treatment with plateletrich plasma (PRP). METHODS: Ultrasound (40 MHz) images were used for measuring pennation angle (PA), muscle thickness (MT) and mean pixel intensity, along with claudication scores, of treated (PRPG) and non-treated (NTG) groups of rats. RESULTS: NTG showed a PA increase for the non-injured leg (p<0.05) and a tendency of MT to increase, whereas for PRPG there were no differences. There was a progressive reduction of the claudication score for the PRPG group throughout the entire period, with an immediate difference after seven days (p<0.05), whereas the NTG had a significant reduction only at day 28 (p<0.05). CONCLUSION: It was observed a compensatory hypertrophic response due to the overload condition imposed to healthy leg for NTG that did not occur in PRPG, suggesting an accelerated repair process of the injured leg due to treatment, anticipating its use.

Laceration in rat gastrocnemius. Following-up muscle repairing by ultrasound biomicroscopy (in vivo), contractility test (ex vivo) and histopathology.

PURPOSE: Implement a laceration protocol of the rat lateral gastrocnemius (LG) and following-up its repair with ultrasound biomicroscopy (UBM), contractility tests and histology. METHODS: Sixty-three male Wistar rats were distributed into two groups. One, with sub-groups GI, GII and GIII (n=12), each containing right LG lacerated (n=6), control and sham (n=3) animals. LG muscles in GI, GII and GIII were inspected by UBM (40 MHz) immediately after, 14 and 28 days post-surgery and thereafter excised with four (GI), 14 (GII) and 28 (GIII) days post-surgery for histology. Animals in second group were distributed into right LG lacerated and control sub-groups. LG muscles in lacerated sub-group were submitted to contractility tests at four (n=8), 14 (n=8) and 28 (n=8) days post-surgery, while in the control sub-group (n=5) were submitted to contractility tests along the course of the experiments. RESULTS: Descriptive findings agreed between the lesion model, muscle repair, UBM images and histology. Contractility results for right LG were different (p<0.05) between control and injured muscle with four and 14 days post-surgery, at tetanic stimulating frequencies (50 and 70 Hz). CONCLUSION: A laceration protocol of the lateral gastrocnemius was implemented and ultrasound biomicroscopy, contractility and histology findings agreed regarding the following-up of injured muscle repair.

Ultrasound biomicroscopy confirmation of corneal overriding due to improper suturing of full-thickness corneal laceration.

We herein present a case with corneal overriding due to improper suturing of a full-thickness corneal laceration. There was a 2.5-mm difference between horizontal and vertical white-to-white measurements in the cornea. However, slit lamp examination failed to demonstrate the exact architecture of the laceration. Ultrasound biomicroscopy defined the wound edges thoroughly and confirmed the presence of corneal overriding. Six weeks after suture enhancement, the abnormal oval appearance of the cornea was absent and correct apposition of the corneal edges was seen on ultrasound biomicroscopy. Ultrasound biomicroscopy can be used in preoperative surgical planning of cases with complicated corneal lacerations. It can be used to adjust and enhance wound architecture in eyes with penetrating injury.

A video-assisted endotracheal suture technique for correction of distal tracheal laceration after intubation.

The incidence of tracheal laceration is 1 of 20,000 intubations. The most frequently affected area is the posterior tracheal wall (membranous). Risk factors include several forced attempts at intubation, inexperience of the clinician, tracheal introducers (guidewires) that protrude beyond the tip of the tube, and emergency procedures. Surgical treatment of tracheal lacerations can be by a transtracheal suture technique or a right thoracotomy. Using the concept of minimally invasive surgical procedures, we reported the treatment of 2 patients with tracheal lacerations greater than 5 cm in the distal trachea that were treated with endotracheal video-assisted suturing using a cervical incision.

Iatrogenic tracheal tear.

Large post intubation tracheal tears are usually detected intra-operatively due to unstable signs namely impaired ventilation and mediastinal emphysema and often require surgical management. Smaller tracheal tears are often missed during anaesthesia and recognized during the postoperative period. Conservative management should be considered in these latter cases.