Heridas por asta de toro, análisis de 138 casos.

OBJECTIVE: Bull-horn injuries (BHI) are unique and there is reduced published literature about it. We present an analysis of a 11-year BHI case series. METHOD: Study of 138 cases developed during a 11-year period with hospitalization admission greater than 24 hours with diagnosis of BHI/contusion. We classified patients in two groups: group A, patients undergoing procedures under general anaesthesia and group B undergoing procedures under local anaesthesia. Variables: age, sex, date, hospitalization length, main region affected, Comprehensive complication index (CCI, ISS, intensive care unit (ICU) admission, stay and mortality. Statistical analysis: t-Student test, ANOVA, χ2 and linear or logistic regression. RESULTS AND CONCLUSIONS: ISS was related to hospital stay, CCI, ICU admission and type of treatment applied. The comparative statistical analysis of variables between both groups determined a significant difference in age, ISS and hospitalization length, being greater in those belonging to group A. There is a more risk of undergoing surgery by increasing age, ISS and presenting the wounds in thorax-abdomen-pelvis area. CCI may be a good method of quantifying postoperatory morbidity in polytraumatized patients or in other areas besides the abdomen.

OBJETIVO: Las heridas por asta de toro (HAT) poseen características únicas y existe literatura escasa en esta área. Presentamos un análisis de 11 años de pacientes con HAT. MÉTODO: Estudio retrospectivo y analítico de 138 casos durante un periodo de 11 años, de pacientes ingresados durante más de 24 horas por HAT. Clasificamos a los pacientes en dos grupos: grupo A, sometidos a procedimientos bajo anestesia general, y grupo B, sometidos a procedimientos bajo anestesia local. Variables recogidas: edad, sexo, mes del suceso, hospitalización (días), región afectada, Comprehensive Complication Index (CCI), Injury Severity Score (ISS), ingreso y estancia en la unidad de cuidados intensivos (UCI) y mortalidad. Análisis estadístico: t de Student, ANOVA, χ2, regresión lineal y logística. RESULTADOS Y CONCLUSIONES: El ISS se relaciona directamente con la estancia hospitalaria, el CCI, el ingreso en UCI y el tratamiento recibido. Entre ambos grupos se evidenció una diferencia significativa en edad, ISS y estancia hospitalaria, siendo mayores en el grupo A. Existe un mayor riesgo de necesitar cirugía conforme aumentan la edad, el ISS y las heridas en tórax, abdomen o pelvis. El CCI puede ser un buen método para cuantificar la morbilidad posoperatoria en pacientes politraumatizados o con lesiones en otras áreas distintas del abdomen.

Lipoma isquiorrectal gigante como causa de dolor anal, incontinencia fecal y dispareunia. Una asociación excepcional / Giant ischiorectal lipoma as a cause of anal pain, fecal incontinence and dyspareunia. An exceptional association

RESUMEN Los lipomas suponen el 50% de los tumores de partes blandas. Podrían comprimir estructuras adyacen tes. Presentamos el caso de una mujer de 49 años con dolor anal intenso asociado a urgencia defecatoria, tenesmo, incontinencia y dispareunia. Presentaba tumoración blanda a nivel del glúteo derecho compa tible con lipoma. La resonancia magnética identificó una masa de 15,7 × 9 × 6 cm, de apariencia encap sulada, que se extendía por la fosa isquioanal e isquiorrectal con impronta sobre el músculo elevador del ano, desplazando el recto. Se efectuó exéresis en bloque, con alta en 48 horas sin complicaciones. El informe de Anatomía Patológica definitivo fue lipoma. Valoramos la asociación de lipoma e incontinencia fecal con una búsqueda en PubMed. Se obtuvieron 87 artículos de los cuales ninguno respondía al objeto del estudio. Esta sintomatología es un fenómeno excepcional en la literatura, que se diagnostica funda mentalmente mediante RM y ecoendoscopia. Gran resultado funcional tras la exéresis.

ABSTRACT Lipomas account for 50% of soft-tissue tumors and may compress adjacent structures. We report the case of a 49-year-old female patient with intense anal pain associated with defecation urgency, tenesmus, incontinence and dyspareunia. A soft tumor was present in the right buttock suggestive of lipoma. On magnetic resonance imaging an apparently encapsulated mass with a size of 15.7 × 9 × 6 cm was identified extending through the ischioanal fossa and ischiorectal fossa, displacing the levator ani muscle and rectum. The lesion was excised en bloc and the patient was discharged 48 hours later without complications. The pathology report concluded that the lesion corresponded to a lipoma. We performed a bibliographic search in PubMed to assess the association between lipoma and fecal incontinence; Of the 87 articles retrieved, none of them responded to the subject of the study. These symptoms are exceptional in the literature. The diagnosis is made mainly with magnetic resonance imaging and endoscopic ultrasound. An excellent functional outcome was achieved with surgical excision.

The Cost of Postoperative Complications and Economic Validation of the Comprehensive Complication Index: Prospective Study.

OBJECTIVE: To validate the Comprehensive Complication Index (CCI) via an assessment of its relation to postoperative costs. BACKGROUND: The CCI summarizes all the postoperative complications graded by the Clavien-Dindo classification (CDC) on a numerical scale. Its relation to hospital costs has not been validated to date. METHODS: Prospective observational cohort study, including all patients undergoing surgery at a general surgery service during the 1-year study period. All complications graded with the CDC and CCI and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. The surgeries were classified according to their Operative Severity Score (OSS) and in 4 groups of homogeneous surgeries. All postoperative costs were recorded. RESULTS: In all, 1850 patients were included, of whom 513 presented complications (27.7%). The CDC and the CCI were moderately to strongly correlated with overall postoperative costs (OPCs) in all OSS groups (rs = 0.444-0.810 vs 0.445-0.820; P < 0.001), homogeneous surgeries (rs = 0.364-0.802 vs 0.364-0.813; P < 0.001), prolongation of postoperative stay (rs = 0.802 vs 0.830; P < 0.001), and initial operating room costs (rs = 0.448 vs 0.451; P < 0.001). This correlation was higher in emergency surgery. With higher CDC grades, the OPC tended to increase an upward trend. In the multivariate analysis, CDC, CCI, age, and duration of surgery were all associated with OPC (P < 0.001). CONCLUSIONS: In our environment, the CCI presented associations with OPC. This demonstration of its economic validity enhances its clinical validity.

Ascitis quilosa en el posoperatorio de hepatectomía derecha / Chylous ascites after right liver resection

La ascitis quilosa posoperatoria (AQP) se debe a acumulación de líquido rico en triglicéridos en la cavidad peritoneal tras una lesión en la cisterna del quilo o en sus afluentes. Es infrecuente verla después de una hepatectomía. Se presenta el caso de un varón de 44 años con adenocarcinoma a 16 cm del margen anal T3N1, con metástasis que ocupaba casi la totalidad del lóbulo hepático derecho. Luego de quimioterapia se realizó hepatectomía derecha, observándose al cuarto día postoperatorio líquido del drenaje endotorácico de aspecto lechoso, con triglicéridos 223 mg/dL y 77 mg/dL de triglicéridos séricos. Se inició dieta sin grasas, hiperproteica, con ácidos grasos de cadena media y octreótide (100 microgramos subcutáneos cada 8 horas), con resolución del cuadro. En conclusión, la complicación quilosa puede tratarse exitosamente con un abordaje menos agresivo, sin suprimir la ingesta oral, utilizando octreótide subcutáneo, dieta exenta de grasas, suplementada con proteínas y ácidos grasos de cadena media.

Postoperative chylous ascites is an intraperitoneal collection of lymphatic fluid enriched with long-chain triglycerides that results from injury of the cisterna chyli or its main tributaries. This complication is rare after liver resections. Here, we report on the case of a 44 year-old man with a T3N1 rectal adenocarcinoma 16 cm above the anal margin, with metastatic compromise of almost the entire right liver lobe. Following chemotherapy, he underwent right liver resection. On postoperative day four, the thoracic drain evidenced milky fluid containing triglyceride 223 mg/dL with serum triglycerides 77 mg/dL. A fat-free diet was indicated with fat-free protein supplements, medium chain triglycerides and octreotide (100 μg subcutaneously every 8 hours), with complete resolution. In conclusion, postoperative chylous complications may be treated successfully by a less aggressive approach, with oral diet, subcutaneous octreotide, fat-free diet supplemented with proteins and medium chain fatty acids.

Clinical Validation of the Comprehensive Complication Index as a Measure of Postoperative Morbidity at a Surgical Department: A Prospective Study.

OBJECTIVE: Using clinical outcomes, to validate the comprehensive complication index (CCI) as a measure of postoperative morbidity in all patients undergoing surgery at a general surgery department. BACKGROUND: The Clavien-Dindo classification (CDC) is the most widely used system to assess postoperative morbidity. The CCI is a numerical scale based on the CDC. Once validated, it could be used universally to establish and compare the real postoperative complications of each surgical procedure. METHODS: Observational prospective cohort study. All patients who underwent surgery during the 1-year study period were included. All the complications graded with the CDC and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. Surgical procedures were classified according to the operative severity score (OSS) as minor, moderate, major, or major+. The clinical validation of the CCI was performed by assessing its correlation with 4 different clinical outcomes. RESULTS: A total of 1850 patients were included: 513 (27.7%) presented complications and 101 (5.46%) were readmitted. In the multivariate analysis, the CCI and CDC were associated with postoperative stay, prolongation of postoperative stay, readmission, and disability in all OSS groups (P < 0.001). The CCI was superior to the CDC in all models except for prolongation of stay for OSS moderate and major+. CONCLUSIONS: The CCI can be applied in all the procedures carried out at general surgery departments. It is able to determine the morbidity and allows the comparison of the outcomes at different services.