Trauma Registry: Trauma Quality indicators analysis in hospitalized patients.

PURPOSE: to consolidate a Trauma Register (TR) trough REDCap data acquisition platform and to validate, in this context, local Quality Indicators (QI) as improvement opportunities in trauma management. METHODS: continuous data acquisition of all patients admitted in Irmandade da Santa Casa de Misericórdia de São Paulo adult Trauma bay and it's validation in REDCap platform; 6 months retrospective cohort of QI impact in length of hospitalar stay, complications and mortality. Fisher, Chi-squared, Wilcoxon and Kruskal-Wallis tests were used to correlate QIs fails with the endpoints, considering p<0.05 and CI <95% as statically significant. RESULTS: 465 were admitted in Trauma bay, with 137 patients hospitalized (29.5%); the number of QIs compromised were related with more complications (p=0.075) and increased length of stay (p=0.028), especially the delay in open fracture's surgical management, which increased the severe complications' incidence (p=0.005). CONCLUSION: the REDCap data acquisition platform is useful as a tool for multi center TR implementation, from ethical and logistical point of view; nevertheless, the proposed QIs are validated as attention points in trauma management, allowing improvements in traumatized patients treatment.

Lymphocintilographic evaluation of lymphatic circulation in victims of circuferential degloving injuries of the lower limbs.

INTRODUCTION: secondary forms of lymphedema may occur as consequence of tumors, surgeries, radiotherapy, trauma and infections. Degloving injuries are severe and infrequent forms of trauma, with avulsion at the level of muscular fascia, and consequent injury of the lymphatic system. OBJECTIVE: to evaluate the alterations in lymphatic circulation in patients being victims of circumferential degloving injuries in the lower limbs, using lymphoscintigraphic. PATIENTS AND METHODS: retrospective analysis of the cases treated in the period from 2010 to 2016. Segmental, circumferential and unilateral injuries with involvement of the lower limbs were included. Lymphoscintigraphy was performed after a minimum interval of 12 months after the end of treatment. The non-injured lower limb was used as control. The Kleinhans Semiquantitative Index (KSI) was used for the semiquantitative evaluation of the lymphoscintigraphic findings. RESULTS: eighteen patients were evaluated, six of whom were female and 12 were male. The mean age was 28.11 years. The average vertical extension of the circumferential traumatized segment was 29.33cm. The injured area presented variations of 5 to 15% of the body surface, with an average of 8.95%. Lymphoscintigraphy was performed after an average interval of 22.55 months. Alterations were observed on the traumatized limb (TL) in 13 patients. All control limbs (CL) were normal. The mean KSI observed in TL was 8.32, while in CL, the average value was 0.58 (p<0.001). CONCLUSION: patients with circumferential degloving injuries in the lower limbs present compromised lymphatic circulation and high probability to develop lymphedema.

Predictors of pleural complications in trauma patients undergoing tube thoracostomy: A prospective observational study.

OBJECTIVE: to identify variables related to pleural complications in patients undergoing tube thoracostomies due to traumatic injuries. METHOD: we conducted a prospective observational study from May/2019 to January/2021 including adult trauma patients submitted to tube thoracostomies after hospital admission. Patients undergoing thoracotomies as the initial treatment were not included. We excluded patients with suspected and confirmed COVID-19 diagnosis during the hospitalization. Pleural complications were defined as clotted hemothorax, residual pneumothorax and empyema. Students t, Mann Whitneys, Chi square and Fishers exact test were used to compare variables between groups. We considered p<0.05 as significant. RESULTS: we analyzed 68 patients. The mean age was 36.0 + 12.6 years and 91.2% were male. The mean RTS and ISS were, respectively, 7.0 ± 1.6 and 15.9 ± 7.6. The most frequent trauma mechanism was stab wounds in 50.0%, followed by blunt trauma in 38.2%. The severity of thoracic injuries was stratified (AIS) as 2 (4.4%), 3 (80.9%), 4 (13.2%), e 5 (1.5%). Pleural complications happened in 14 (20.5%) patients, being clotted / residual hemothorax (11.8%), residual pneumothorax (4.4%), empyema (2.9%) and miscellaneous (1.4%). These patients were treated by thoracoscopy (5), thoracotomy (3), chest re-drainage (3) and clinical measures alone (3). There was a significant association between pleural complications with the time of permanence (p<0,001) and the necessity of relocation (p<0,001) of the drain. CONCLUSION: the predictors of pleural complications in this series were time of permanence and the necessity of relocation of the drain.

The role of autopsy on the diagnosis of missed injuries and on the trauma quality program goal definitions: study of 192 cases.

OBJECTIVE: to assess the role of autopsy in the diagnosis of missed injuries (MI) and definition of trauma quality program goals. METHOD: Retrospective analysis of autopsy reports and patient's charts. Injuries present in the autopsy, but not in the chart, were defined as "missed". MI were characterized using Goldman's criteria: Class I, if the diagnosis would have modified the management and outcome; Class II, if it would have modified the management, but not the outcome; Class III, if it would not have modified neither the management nor the outcome. We used Mann-Whitney's U and Pearson's chi square for statistical analysis, considering p<0.05 as significant. RESULTS: We included 192 patients, with mean age of 56.8 years. Blunt trauma accounted for 181 cases, and 28.6% were due to falls from the same level. MI were diagnosed in 39 patients (20.3%). Using Goldman's criteria, MI were categorized as Class I in 3 (1.6%) and Class II in 11 (5.6%). MI were more often diagnosed in the thoracic segment (25 patients, 64.1% of the MI). The variables significantly associated (p<0.05) to MI were: time of hospitalization < 48 h, severe trauma mechanism, and not undergoing surgery or computed tomography. At autopsy, the values of ISS and NISS were higher in patients with MI. CONCLUSION: the review of the autopsy report allowed diagnosis of MIs, which did not influence outcome in their majority. Many opportunities of improvement in quality of care were identified.

Clinical assessment of head injuries in motorcyclists involved in traffic accidents: A prospective, observational study.

OBJECTIVE: to review the clinical assessment of head injuries in motorcyclists involved in traffic accidents. METHOD: prospective observational study, including adult motorcyclists involved in traffic accidents in a period of 12 months. Patients sustaining signs of intoxication were excluded. A modification of the Canadian Head CT Rules was used to indicate computed tomography (CT). Patients not undergoing CT were followed by phone calls for three months. Collected variables were compared between the group sustaining head injuries and the others. We used chi-square, Fisher, and Student's t for statistical analysis, considering p<0.05 as significant. RESULTS: we included 208 patients, 99.0% were wearing helmets. Seventeen sustained signs of intoxication and were excluded. Ninety (47.1%) underwent CT and 12 (6.3%) sustained head injuries. Head injuries were significantly associated with Glasgow Coma Scale<15 (52.3% vs. 2.8% - p<0,001) and a positive physical exam (17.1% vs. zero - p<0,05). Four (2.1%) patients with intracranial mass lesions needed surgical interventions. None helmet-wearing patients admitted with GCS=15 and normal physical examination sustained head injuries. CONCLUSION: Head CT is not necessary for helmet-wearing motorcyclists admitted with GCS=15 and normal physical examination.

Blunt gastric rupture: a plural clinical presentation and literature review.

Blunt trauma is still the leading mechanism of trauma found in patients admitted to trauma centres worldwide. In these patients, the gastric injury is a very rare lesion, occurring in less than 2% of all blunt traumas. Besides the low incidence, gastric rupture mortality is high, which makes the diagnosis an essential step. Thus, this study aims to report two blunt gastric injuries, with different clinical features, prompting the discussion about the main features of clinical suspicion and diagnosis, besides the main therapeutic approaches. Therefore, this study can alert the medical community to the quick diagnosis and assertive therapy, saving patients of unwelcome endpoints.

Trauma Quality Indicators' usage limitations in severe trauma patients.

PURPOSE: to analyze the relation between Trauma Quality Indicators (QI) and death, as well as clinical adverse events in severe trauma patients. METHODS: analysis of data collected in the Trauma Register between 2014-2015, including patients with Injury Severity Score (ISS) > 16, reviewing the QI: (F1) Acute subdural hematoma drainage > 4 hours with Glasgow Coma Scale (GCS) <9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours; (F4) Admission-laparotomy time greater than 60 min in hemodynamically instable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time > 6 hours; (F10) Surgery > 24 hours. T the chi-squared and Fisher tests were used to calculate statistical relevance, considering p<0.05 as relevant. RESULTS: 127 patients were included, whose ISS ranged from 17 to 75 (28.8 + 11.5). There were adverse events in 80 cases (63%) and 29 died (22.8%). Twenty-six patients had some QI compromised (20.6%). From the 101 patients with no QI, 22% died, and 7 of 26 patients with compromised QI (26.9%) (p=0.595). From the patients with no compromised QI, 62% presented some adverse event. From the patients with any compromised QI, 18 (65.4%) had some adverse event on clinical evolution (p=0.751). CONCLUSION: the QI should not be used as death or adverse events predictors in severe trauma patients.

Management of acute appendicitis during the COVID-19 pandemic: Views of two Brazilian surgical societies.

Acute appendicitis (AA) is a frequent cause of abdominal pain requiring surgical treatment. During the COVID-19 pandemic, surgical societies considered other therapeutic options due to uncertainties in the evolution of the disease. The purpose of this study is to assess the treatment of AA by members of two Brazilian surgical societies in this period. A common questionnaire was sent in 2020. There were 382 responses. Most surgeons had more than 15 years of profession (68.3%) and treated more than five cases per month (44.8%). About 72.5% would indicate chest CT to investigate COVID-19 in patients with AA. For those patients sustaining uncomplicated AA, without COVID-19, 60.2% would indicate laparoscopic appendectomy (VLA), followed by open appendectomy (OA) (31.7%) and non-operative management (NOM) (1.3%). For those with mild COVID-19, OA was suggested by 51.0%, followed by VLA (29.6%) and NOM (6.0%). For those with severe COVID-19, OA was proposed by 35.3%, followed by NOM (19.9%) and VLA (18.6%). For patients with periappendiceal abscesses, without COVID-19, VLA was suggested by 54.2%, followed by OA (33.2%) and NOM (4.4%). For those with mild COVID-19, OA was proposed in 49.5%, followed by VLA (29.3%) and NOM (8.9%). In those with severe COVID-19, OA was proposed in 36.6%, followed by NOM (25.1%) and VLA (17.3%). This information, based on two recognized Brazilian surgical societies, can help the surgeon to select the best approach individually.

Optimizing Pelvic X-Ray indication in blunt trauma patients using clinical criteria.

OBJECTIVE: to identify a subgroup of blunt trauma patients with very low chance of sustaining pelvic fractures based on clinical criteria. METHODS: retrospective analysis of the trauma registry data, collected in a period of 24 months. We selected adult blunt trauma patients who had a PXR on admission. The frequency of pelvic fractures was calculated for the following groups: Normal neurological examination at admission (NNE), hemodynamical stability (HS), normal pelvic examination at admission (NPE), less than 60 years old (ID<60) and absence of distracting injuries (ADI). Logistic regression analysis was carried out in order to create a probability model of negative PXR. RESULTS: an abnormal PXR was identified in 101 (3.3%) out of the 3,055 patients who had undergone a PXR at admission. Out of these, 1,863 sustained a NNE, with 38 positive CXRs (2.0%) in this group. Considering only the 1,535 patients with NNE and HS, we found 28 positive PXRs (1.8%). Out of these, 1,506 have NPE, with 21 abnormal PXRs (1.4%). Of these, 1,202 were younger than 60 y, with 11 positive PXRs (0.9%). By adding all these criteria to the ADI, we found 2 abnormal PXRs in 502 (0.4%) cases. The probability model including all these variables had a 0,89 area under the ROC curve. CONCLUSIONS: by adding clinical criteria, it is possible to identify a group of trauma patients with very low chance of sustaining pelvic fractures. The necessity of PXR in these patients needs to be reassessed.

Trauma quality indicators: a way to identify attention points in the treatment of elderly trauma patients.

PURPOSE: to trauma quality indicators as a tool to identify opportunities of improvement in elderly trauma patient's' treatment. METHODS: prospective analysis of data collected between 2014-2015, and stored in the iTreg software (by Ecossistemas). Trauma victims, aged older than 60 years and trauma quality indicators were assessed, based on those supported by SBAIT in 2013: (F1) Acute subdural hematoma drainage after 4 hours from admission, in patients with GCS<9; (F2) emergency room transference without definitive airway and GCS <9; (F3) Re-intubation within 48 hours from extubation; (F4) Admission-laparotomy time greater than 60 min. in hemodynamically uinstable patients with abdominal bleeding; (F5) Unprogrammed reoperation; (F6) Laparotomy after 4 hours from admission; (F7) Unfixed femur diaphyseal fracture; (F8) Non-operative treatment for abdominal gunshot; (F9) Admission-tibial exposure fracture treatment time greater than 6 hours; (F10) Surgery after 24 from admission. The indicators, treatments, adverse effects and deaths were analyzed, using the SPSS software, and the chi-squared and Fisher tests were used to calculate the statistical relevance. RESULTS: from the 92 cases, 36 (39,1%) had complications and 15 (16,3%) died. The adequate use of quality indicator's were substantially different among those who survived (was of 12%) compared to those who died (55,6%). The incidence of complications was of 77,8% (7/9) in patients with compromised indicators and 34,9% (28/83) in those without (p=0.017). CONCLUSIONS: trauma quality indicators are directly related with the occurrence of complications and deaths, in elderly trauma patients.

Management of non traumatic surgical emergencies during the COVID-19 pandemia.

In December 2019, in Wuhan, China, the first cases of what would be known as COVID-19, a disease caused by an RNA virus called SARS-CoV-2, were described. Its spread was rapid and wide, leading the World Health Organization to declare a pandemic in March 2020. The disease has distinct clinical presentations, from asymptomatic to critical cases, with high lethality. Parallel to this, patients with non-traumatic surgical emergencies, such as acute appendicitis and cholecystitis, continue to be treated at the emergency services. In this regard, there were several doubts on how to approach these cases, among them: how to quickly identify the patient with COVID-19, what is the impact of the abdominal surgical disease and its treatment on the evolution of patients with COVID-19, in addition to the discussion about the role of the non-operative treatment for abdominal disease under these circumstances. In this review, we discuss these problems based on the available evidence.

Duodenal diverticulization as treatment of complex duodeno-pancreatic lesions: Case report.

INTRODUCTION: Duodenal and pancreatic lesions are uncommon, but severe and responsible for high incidence in morbidity and mortality. Differences between the mechanisms of trauma, the severity of lesions and the time between trauma, diagnosis and treatment influence the evolution of the case. PRESENTATION OF CASE: We report a case of a 20-year-old patient with several lesions in stomach, duodenum, pancreas and jejunum due to three gunshots treated at our service. Duodenal diverticulalization was used on treatment of complex duodeno-pancreatic lesions. The patient presented good evolution, with discharge conditions in the 10th PO. DISCUSSION: We discussed the positives and negatives of this technique, with the approval of the Ethics Committee number 13736519.8.0000.5479. CONCLUSION: The duodenal diverticulization leads to an irreversible change to the food transit. However, this is a feasible bypass option in cases of high chances of fistula and scar stenosis complex duodenal injury, particularly in the context of associated gastric injury.

Hepatic subcapsular hematoma post-ERCP: Case report and literature review.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed minimally invasive procedures currently available for diagnosis and treatment of biliary and pancreatic diseases. Though considered a safe procedure, it has the highest rate of complications among the other endoscopic procedures, such as duodenal perforation and hepatic subcapsular hematoma (HSH). We are a presenting a case report and review of the current literature. METHOD: We report one case HSH rupture, in a 25 years old female patient, 15 cm in diameter, affecting liver segments VI, VII and VIII, who underwent surgical treatment and performed a systematic literature review with the descriptors: endoscopic retrograde colangiopancreatography and hepatic subcapsular hematoma. All articles were reviewed and data on cases that presented rupture of the HSH analyzed separately. RESULTS: Sixty one cases of HSH were described in the literature, fourteen of them ruptured. When analyzing only the subgroup of patients who had ruptured subcapsular hematoma, we showed a significant increase in the mortality rate of patients when compared to non-ruptured (21.4% × 2.2%). We also report that patients with rupture required some type of intervention, of which 78.6% required surgery. Conservative treatment may be the conduct and will suffice for most cases of non-ruptured hematomas. For patients who evolve with rupturing, surgical resolution, although non-mandatory, is necessary in most cases. CONCLUSION: HSH ruptured is a rare and potentially fatal post-ERCP complication whose treatment is eminently surgical.

Doppler ultrasound could predict varices progression and rebleeding after portal hypertension surgery: lessons from 146 EGDS and 10 years of follow-up.

BACKGROUND: Surgical treatment of variceal hemorrhagic complications for patients with schistosomal portal hypertension in our group comprised an esophagogastric devascularization procedure with splenectomy (EGDS). There are two different kinds of postoperative follow-up: prophylactic or on-demand endoscopic program of varices eradication. This program implies risks and costs and only proves necessary in 6-29% of cases. This study was designed to assess portal vein Doppler ultrasound data in these patients, and to verify correlations with progression in the number and size of varices, as well as the appearance of red spots and rebleeding during the postoperative period after EGDS. METHODS: Data on portal vein Doppler ultrasound from 146 patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophagogastric varices rupture was analyzed. All subjects underwent EGDS and were analyzed before and after the procedure and compared postoperatively at four time points: 1 year, 2 years, up to 5 years, and up to 10 years. The following portal hemodynamic parameters were analyzed: diameter and mean blood flow velocity. Variceal size and number, presence of red spots, and rebleeding were all determined by endoscopic examination. Patients were divided into two groups at the each of the four time points, according to esophagogastric varices progression. RESULTS: Patients with variceal progression had significantly higher values of portal blood flow velocity. At time points I, II, III, and IV, the measured flow velocity from first postoperative year was 17.64 +/- 4.84 vs. 13.81 +/- 5.61 (p = 0.025); 16.74 +/- 4.8 vs. 13.75 +/- 5.8 (p = 0.039); 16.01 +/- 5.00 vs. 13.23 +/- 5.86 (p = 0.036); and 16.01 +/- 5.00 vs. 13.23 +/- 5.86 (p = 0.036), respectively. CONCLUSIONS: Patients with schistosomal portal hypertension submitted to EGDS who had portal blood flow velocity >15.5 cm per second at the first postoperative year ha d progression of esophagogastric varices and a greater chance of rebleeding and, therefore, should be included in the endoscopic program for varices eradication.

[Undetected surgical glove perforation during emergency procedures]. / Perfurações não detectadas de luvas em procedimentos de urgência.

OBJECTIVE: Gloves are the most important barriers that protect hospital personnel and patients. Unfortunately, glove perforation rates reach up to 78% in high risk procedures. The purpose of this prospective study was to evaluate the glove perforation rate in emergency procedures carried out in the Emergency Service of 'Santa Casa de São Paulo', School of Medicine. METHODS: The study analyzed all gloves used in the emergency room during a 2 months period. Gloves were tested immediately after the surgical procedure using the approved standardized water leak method. RESULTS: A total of 252 surgical gloves used by residents in 42 surgical procedures and 2361 gloves used in emergency procedures were tested for the presence of punctures by the water insuflation method. Forty one (16.3%) of the gloves tested showed at least one puncture, 18 (33%) in traumatic emergencies. The overall perforation rate in the emergency room was 7,3%. CONCLUSION: We concluded that the incidence of punctures in gloves during surgical procedures was high, and occurred mostly with surgeons.

Assessment of risk factors associated with falls among the elderly in a municipality in the state of Paraíba, Brazil. A cross-sectional study.

BACKGROUND: Falls among the elderly are one of the main public health problems that have direct consequences for their health. They reduce these individuals' autonomy and functional independence. OBJECTIVE: The objective of this study was to evaluate the risk factors associated with falls among elderly people enrolled within primary healthcare. DESIGN AND SETTING: Cross-sectional study conducted at primary healthcare units in the municipality of Patos, state of Paraíba, Brazil. METHODS: The Fall Risk Score and Timed Up and Go (TUG) test were used for evaluating the risk of falling among 316 elderly individuals. The independent variables used were sociodemographic and health conditions, while the dependent variable was the frequency of falls on the same level, over the course of previous years. The descriptive statistical tests used were the chi-square and Mann-Whitney tests. RESULTS: Occurrence of falls was reported by 211 of the 316 participants, representing a prevalence of 66.8% with confidence interval 61.6-72.0. The logistic regression results showed, after adjusting for all variables included in the model, that only the variables of vestibular disorders, self-assessed health status and dizziness/vertigo (trend) were significant (P ≤ 0.05). Most of the elderly participants had two or more associated pathological conditions. The participants were predominantly female (68.4%). CONCLUSIONS: Higher occurrence of falls was observed among female elderly individuals who suffered recurrent falls, had had low levels of schooling, presented comorbidities, had comorbidities and made use of drugs. These conditions predisposed these individuals to greater vulnerability to the risk of falls.

Trauma Registry: Trauma Quality indicators analysis in hospitalized patients / Registro de Trauma: análise dos Filtros de Qualidade nos pacientes internados

ABSTRACT Purpose: to consolidate a Trauma Register (TR) trough REDCap data acquisition platform and to validate, in this context, local Quality Indicators (QI) as improvement opportunities in trauma management. Methods: continuous data acquisition of all patients admitted in Irmandade da Santa Casa de Misericórdia de São Paulo adult Trauma bay and it's validation in REDCap platform; 6 months retrospective cohort of QI impact in length of hospitalar stay, complications and mortality. Fisher, Chi-squared, Wilcoxon and Kruskal-Wallis tests were used to correlate QIs fails with the endpoints, considering p<0.05 and CI <95% as statically significant. Results: 465 were admitted in Trauma bay, with 137 patients hospitalized (29.5%); the number of QIs compromised were related with more complications (p=0.075) and increased length of stay (p=0.028), especially the delay in open fracture's surgical management, which increased the severe complications' incidence (p=0.005). Conclusion: the REDCap data acquisition platform is useful as a tool for multi center TR implementation, from ethical and logistical point of view; nevertheless, the proposed QIs are validated as attention points in trauma management, allowing improvements in traumatized patients treatment.

RESUMO Objetivo: implementação de Registro de Trauma (RT) através da plataforma REDCap e validação dos Filtros de Qualidade (FQ) desenvolvidos como pontos de melhora no atendimento ao traumatizado. Métodos: implementação de coleta contínua dos dados de todos os pacientes adultos admitidos na sala de Trauma da Irmandade da Santa Casa de Misericórdia de São Paulo e validação destes na plataforma REDCap; realizada coorte retrospectiva dos dados validados em um período de 6 meses e o impacto dos FQ desenvolvidos no tempo de internação hospitalar, complicações e mortalidade dos pacientes. A correlação do comprometimento dos FQ com os desfechos foi obtida através dos testes de Fisher, Qui-Quadrado, Wilcoxon e Kruskal-Wallis, considerando p<0,05 e IC 95% como significativos. Resultados: incluídos no estudo 465 pacientes admitidos no período de estudo, com necessidade de internação em 137 casos (29,5%); o número de FQs comprometidos relacionou-se com maior número de complicações (p=0,075) e maior tempo de internação (p=0,028), sobretudo o atraso na ida ao Centro Cirúrgico de fraturas expostas, que aumentou a incidência de complicações graves (p=0,005). Conclusão: a plataforma REDCap é adequada e útil na implementação de RT, permitindo o uso ético e multicêntrico de dados; os FQs propostos determinam pontos de atenção a serem revistos no atendimento do trauma, permitindo melhorias na qualidade de atendimento ao paciente traumatizado.

Morbimortality indicators in severe acute pancreatitis.

OBJECTIVE: The aim of this study was to determine the factors related to the development of systemic complications, mortality and pancreatic necrosis in patients with severe acute pancreatitis. PATIENTS: Thirty-nine patients (22.3%) out of 175 patients with acute pancreatitis who were admitted to our center, had an APACHE II score greater than 8; they were classified as having severe acute pancreatitis and were evaluated in the study. MAIN OUTCOME MEASURES: Sepsis-related Organ Failure Assessment (SOFA) and Marshall scores were obtained. The variables analyzed were age, sex, etiology, hematocrit, leukocyte count, CRP level, CT findings and length of hospital stay. These variables were related to the development of systemic complications, mortality and necrotizing pancreatitis. RESULTS: The mean APACHE II value of the patients included was 11.6+/-3.1, the mean SOFA score was 3.2+/-2.0 and the Marshall score was 1.5+/-1.9. Eleven patients developed necrotizing pancreatitis. The mortality rate among severe acute pancreatitis patients was 3 out of 39 (7.7%). Variables found to be related to systemic complications were the APACHE II score as well as SOFA and Marshall scores greater than 3. The variables related to mortality were SOFA score greater than 3 and leukocytosis greater than 19,000 mm(-3). CRP greater than 19.5 mg/dL and length of hospital stay were related to necrotizing pancreatitis. CONCLUSIONS: The scoring systems, especially the SOFA score, were related to the development of systemic complications and mortality. CRP showed a relationship to necrotizing pancreatitis. There was no relationship between the evaluated scoring systems and necrotizing pancreatitis in patients with severe acute pancreatitis.

Malignant transformation of abdominal wall endometriosis to clear cell carcinoma: case report.

BACKGROUND: Malignant transformation of endometriosis in the abdominal wall is a rare and still poorly understood event. Less than 30 cases have been reported in the worldwide literature. Most cases of solid tumors are report in a previous abdominal scar with malignant transformation of a focus of endometriosis. Presence of lymph node metastases in nearby chains is frequent and is associated with poor prognosis. CASE REPORT: We report a case of a 42-year-old woman with a history of abdominal surgery (Pfannenstiel) to resect abdominal wall endometriosis. Physical examination revealed a solid mass of approximately 10 cm x 6 cm in the anterior wall of the abdomen. Computed tomography (CT) of the abdomen and pelvis showed a heterogeneous, predominantly hypoattenuating expansive formation measuring 10.6 cm x 4.7 cm x 8.3 cm. The patient underwent exploratory incisional laparotomy, block resection of the abdominal mass and lymphadenectomy of the external and inguinal iliac chains. The abdominal wall was reconstructed using a semi-absorbable tissue-separating screen to reconstitute the defect caused by resection of the tumor. Histological evaluation revealed infiltration by malignant epithelioid neoplasia, thus confirming the immunohistochemical profile of adenocarcinoma with clear cell components. Lymphadenectomy showed metastatic involvement of an external iliac chain lymph node. CONCLUSION: Resection of the mass along with the abdominal wall, with wall margins, is the most effective treatment. Reconstruction is a challenge for surgeons. The patient has been followed up postoperatively for eight months, without any evidence of disease to date.

IMPACT OF BARIATRIC SURGERY ON THE INFLAMMATORY STATE BASED ON CPR VALUE.

BACKGROUND: PCR (C-reactive protein), produced in the liver after stimuli of inflammatory mediators, is determined as a marker of inflammatory activity (adipocytokines) and is present within adipocyte cells; besides being an inflammatory product, many studies have shown to be a predictor of complications. AIM: To determine if the inflammatory state of the obese patient decreases after bariatric surgery, based on pre and post-operative PCR. METHODS: A prospective, observational study in patients undergoing Roux-en-Y gastric by-pass surgery followed up for three months after surgery, with serum preoperative CRP in 30, 60 and 90 days after surgery. RESULTS: A total of 19 patients, who had a mean CRP value before the surgical procedure of 0.80(±0.54) mg/dl, were followed, and when compared to the CRP with 30 days of surgery, they presented a significant increase to 2.68 mg/dl (p=0.012). When compared with the PCR of 60 days after the surgical procedure, it was also higher with the value of 3.32 mg/dl (p=0.27). However, at three months after surgery, the CRP showed a decrease when compared to the preoperative mark, with value of 0.45 mg/dl (p=0.0042). CONCLUSION: Roux-en-Y gastric bypass was able to decrease the chronic inflammation status of these patients, based on the value of CRP, with three months of surgery.