Manejo Conservador del Trauma Penetrante Abdominal

Selective Nonoperative Management of Penetrating Abdominal Solid Organ Injuries.
Original Articles and Discussions Annals of Surgery. Scientific Papers of the 126th Annual Meeting of the American Surgical Association. 244(4):620-628, October 2006.Demetriades, Demetrios MD, PhD; Hadjizacharia, Pantelis MD; Constantinou, Costas MD; Brown, Carlos MD; Inaba, Kenji MD; Rhee, Peter MD; Salim, Ali MD
Abstract: Objective: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries.
Background: Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs.
Patients and Methods: Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay.
Results: During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications.
Conclusions: In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.

Necrosectomía pancreatica laparoscópica

En el último tiempo se ha discutido bastante la posibilidad de realizar necrosectomías por vía laparóscopica en pacientes con pancreatitis aguda infectada. A continuación esta el resumen de un trabajo publicado en el Archives of Surgery que incluye 23 pacientes.

Laparoscopic-Assisted Pancreatic Necrosectomy
A New Surgical Option for Treatment of Severe Necrotizing Pancreatitis
Dilip Parekh, MD
Arch Surg. 2006;141:895-903.
Hypothesis Open surgery for pancreatic debridement is often associated with major morbidity such as wound complications, fascial dehiscence, and intestinal fistulae. Hand-assisted laparoscopic surgery (HALS) is useful for complex abdominal procedures since the benefits of traditional laparoscopic surgery are retained. Published experience with HALS for pancreatic debridement is limited to anecdotal case reports.
Setting University-affiliated private and public hospitals.
Patients Twenty-three patients with necrotizing pancreatitis were evaluated and 19 patients underwent pancreatic debridement from 2001 to 2006. A GelPort (Applied Medical, Rancho Santa Margarita, Calif) was used to provide laparoscopic hand access. In the majority of the patients, an infracolic approach was used to access the pancreatic necrosis.
Results Nineteen patients underwent laparoscopic evacuation of pancreatic necrosis, and in 18 patients, the procedure was completed. The mean age was 54 years; the mean ± SEM body mass index, calculated as weight in kilograms divided by height in meters squared, was 32.0 ± 2.6; the mean American Society of Anesthesiologists score was 3.4; and 7 of 19 patients had past history organ failure. The mean ± SEM operating time was 153 ± 10 minutes and mean ± SEM blood loss was 352.6 ± 103 mL. Four patients required reoperations, 2 using HALS and 2 open. There were no postoperative complications related to the HAL procedure itself, such as major wound infections, intestinal fistulae, or postoperative hemorrhage. Postoperative computed tomographic scans confirmed adequacy of debridement. The mean ± SEM length of hospital stay after surgery was 16.3 ± 3.8 days.

Conclusions This is the largest reported study of laparoscopic debridement for pancreatic necrosis. The procedure is feasible and associated with a low morbidity and mortality. Pancreatic debridement with HALS may provide a new option for the surgical treatment of selected patients with severe necrotizing pancreatitis.

Seguridad para los pacientes

La seguridad de los pacientes debe ser una de nuestras preocupaciones constantes. La revista Contemporary Surgery toca este tema en su edición de septiembre. Formato PDF en inglés.

http://www.contemporarysurgery.com/pdf/6209/6209CS_Symp.pdf