Tomografía Computada y Trauma

The Sensitivity of Computed Tomography (CT) Scans in Detecting Trauma: Are CT Scans Reliable Enough for Courtroom Testimony?
Journal of Trauma-Injury Infection & Critical Care. 63(3):625-629, September 2007.
Molina, D Kimberley MD; Nichols, Joanna J. BA; DiMaio, Vincent J. M. MD

Background: Rapid and accurate recognition of traumatic injuries is extremely important in emergency room and surgical settings. Emergency departments depend on computed tomography (CT) scans to provide rapid, accurate injury assessment. We conducted an analysis of all traumatic deaths autopsied at the Bexar County Medical Examiner's Office in which perimortem medical imaging (CT scan) was performed to assess the reliability of the CT scan in detecting trauma with sufficient accuracy for courtroom testimony.

Methods: Cases were included in the study if an autopsy was conducted, a CT scan was performed within 24 hours before death, and there was no surgical intervention. Analysis was performed to assess the correlation between the autopsy and CT scan results. Sensitivity, specificity, positive predictive value, and negative predictive value were defined for the CT scan based on the autopsy results.

Results: The sensitivity of the CT scan ranged from 0% for cerebral lacerations, cervical vertebral body fractures, cardiac injury, and hollow viscus injury to 75% for liver injury.

Conclusions: This study reveals that CT scans are an inadequate detection tool for forensic pathologists, where a definitive diagnosis is required, because they have a low level of accuracy in detecting traumatic injuries. CT scans may be adequate for clinicians in the emergency room setting, but are inadequate for courtroom testimony. If the evidence of trauma is based solely on CT scan reports, there is a high possibility of erroneous accusations, indictments, and convictions.

Estratificación de Riesgos en Cirugía de Urgencia: Comparación de 4 Sistemas

Comparison of different methods of risk stratification in urgent and emergency surgery
British Journal of Surgery 2007; 94(10):1300-5
W. D. Neary, D. Prytherch, C. Foy, B. P. Heather, J. J. Earnshaw.

The aim was to compare a number of risk scoring systems prospectively in a cohort of patients who underwent non-elective surgery.

This was a cohort study of 2349 consecutive patients who had urgent or emergency surgery in a district general hospital in the UK.

All patients were scored prospectively using the Revised Goldman Cardiac Risk Index (RGCRI), Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), Surgical Risk Score (SRS) and Biochemistry and Haematology Outcome Models (BHOM).

Actual 30-day and 1-year survival rates were compared with the predicted outcomes using receiver-operator characteristic (ROC) curves and Hosmer-Lemeshow analysis.Some 141 patients (6·0 per cent) died within 30 days of operation. This increased to 254 (10·8 per cent) by 1 year. The area under the ROC curve for death within 30 days was 0·90 for P-POSSUM, 0·85 for SRS, 0·84 for BHOM and 0·73 for RGCRI. Only the first three risk scores were able to discriminate accurately within the groups (area under ROC curve over 0·8), with no significant variation between expected and observed mortality rates confirmed by Hosmer-Lemeshow analysis. Similar results were found for the ability of each score to predict outcome at 1 year.

P-POSSUM, SRS and BHOM scoring systems were all able to predict outcome after emergency and urgent surgery, but the SRS had the advantage of ease of calculation.

BHOM requires only the most commonly available blood test data and the computer holding these data can easily perform the calculation.

Bolsa de Bogotá

Experiencia con la técnica de la bolsa de Bogotá para el cierre temporal del abdomen
Antonia Brox-Jiménez, Virgilio Ruiz-Luque, Cristina Torres-Arcos, Pablo Parra-Membrives, Daniel Díaz-Gómez, Lourdes Gómez-Bujedo, Macarena Márquez-Muñoza.
Cir Esp 2007;82:150-4

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Introducción. La bolsa de Bogotá es uno de los dispositivos que se han descrito para el cierre temporal del abdomen. El objetivo de este trabajo ha sido describir nuestra experiencia con la técnica de la bolsa de Bogotá.

Material y método. Analizamos retrospectivamente nuestra experiencia entre enero de 2000 y marzo de 2006. Se aplicó estadística descriptiva con cálculo de porcentajes y medias.

Resultados. En un total de 12 pacientes se empleó la bolsa de Bogotá. En 11 (91,66%) se colocó de forma preventiva por presentar riesgos de hipertensión intraabdominal y síndrome compartimental abdominal. En un paciente (8,34%) la descompresión con bolsa de Bogotá se realizó una vez el síndrome compartimental se había instaurado. No hemos tenido ninguna complicación en relación con la colocación ni la retirada de la bolsa de Bogotá. En ningún caso aparecieron fístulas intestinales ni colecciones infectadas intraabdominales. La estancia media hospitalaria fue de 46,33 días y en la unidad de cuidados intensivos, de 16,58 días. En la actualidad 7/12 (58,34%) han fallecido y 5/12 (41,66%) viven.

Conclusiones. La bolsa de Bogotá para el open abdomen en nuestra serie ha sido un método útil para evitar o tratar el síndrome compartimental abdominal. La gran mortalidad descrita viene dada por el proceso inicial que presentan los pacientes y no por las complicaciones derivadas de la colocación de la bolsa de Bogotá.

Cirugía de la Pancreatitis Crónica

Surgery of chronic pancreatitis
The American Journal of Surgery Volume 194, Issue 4, Supplement 1, October 2007, Pages S53-S60
Charles F. Frey M.D.a and Dana K. Andersen M.D.b, ,

Chronic pancreatitis is a progressive disease of multiple etiologies. Surgery is frequently indicated for relief of debilitating pain as well as to address other complications, and three operations have proven effective. The pancreatico-duodenectomy (Whipple) procedure results in excellent long-term pain relief, but is associated with a low mortality rate and a persistent risk of early and late complications. The duodenum-preserving pancreatic head resection (DPPHR) introduced by Beger et al, and the local resection of the pancreatic head with longitudinal pancreatico-jejunostomy (LR-LPJ) devised by Frey, achieve the same high rate of pain relief long term but are associated with lower rates of perioperative complications and a decreased incidence of diabetes long term. All 3 operations address the head of the pancreas as the nidus of persistent inflammation, and all 3 achieve success with both dilated and nondilated duct disease. The LR-LPJ has a lower risk of perioperative problems and may be easier to perform.

Disfunción Hipofisiaria tras Trauma Cerebral y Hemorragias Subaracnoides

Hypothalamopituitary Dysfunction Following Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage A Systematic Review
Harald Jörn Schneider; Ilonka Kreitschmann-Andermahr; Ezio Ghigo; Günter Karl Stalla; Amar Agha.
JAMA. 2007;298:1429-1438.

Context Neuroendocrine dysfunction following traumatic brain injury and aneurysmal subarachnoid hemorrhage may occur with a much higher prevalence than previously suspected. This sequela is a potentially serious but treatable complication of brain injury.

Objective To review research on hypothalamopituitary dysfunction as an underdiagnosed consequence of traumatic brain injury and subarachnoid hemorrhage, the natural history of this complication, and the potential clinical and public health implications of posttraumatic hypopituitarism.

Evidence Acquisition The MEDLINE database was searched for articles published between 2000 and 2007 using any combination of the terms traumatic brain injury or subarachnoid hemorrhage with pituitary, hypopituitarism, growth hormone deficiency, hypogonadism, hypocortisolism, hypothyroidism, or diabetes insipidus. The reference lists of articles identified by this search strategy were also searched. All articles reporting original data on endocrine outcomes after traumatic brain injury or aneurysmal subarachnoid hemorrhage in peer-reviewed journals with regard to prevalence, pathogenesis, risk factors, outcomes, and clinical course were selected. We pooled data and calculated prevalence rates and 95% confidence intervals (CIs).

Results We identified 19 studies including 1137 patients. The pooled prevalences of hypopituitarism in the chronic phase after traumatic brain injury and aneurysmal subarachnoid hemorrhage were 27.5% (95% confidence interval [CI], 22.8%-28.9%) and 47% (95% CI, 37.4%-56.8%), respectively. The pooled prevalence of hypopituitarism was greater in patients with severe compared with those with mild or moderate traumatic brain injury. Early neuroendocrine abnormalities were transient in some patients while, less commonly, hypopituitarism evolved over time in others. Patients with posttraumatic hypopituitarism showed an impaired quality of life and an adverse metabolic profile.

Conclusion Hypopituitarism is a common complication of both traumatic brain injury and aneurysmal subarachnoid hemorrhage and might contribute to morbidity and poor recovery after brain injury.

Laparoscopía en Quistes y Tumores Hepáticos

Revisión sistématica de la literatura sobre la efectividad de la cirugía minimamente invasiva en el manejo de los tumores y quistes hepáticos. Artículo de cirugía basada en evidencia publicada en la Revista Chilena de Cirugía.

Artículo completo en PDF. Para acceder a él hacer doble click en el título de este entry.

Factores de Riesgo para Empiema Pleural Postraumático

The risk factors and management of posttraumatic empyema in trauma patients
Sevval Eren , Hidir Esme, Abidin Sehitogullari and Atilla Durkan
Injury Available online 19 September 2007.

Background
Posttraumatic empyema increases patient morbidity, mortality and length of hospital stay, and the cost of treatment. The aim of this study was to identify the risk factors for posttraumatic empyema and to review our treatment outcomes in patients with this condition.

Methods
A total of 2261 patients who were admitted with thoracic traumas and underwent tube thoracostomy between January 1989 and January 2006 were investigated retrospectively. Posttraumatic empyema developed in 71 patients. Logistic regression was used to assess the association between potential risk factors for posttraumatic empyema. All values were expressed as the mean ± S.D.

Results
Eight hundred and thirty-six (37%) of the patients had penetrating type trauma, while 1425 (63%) had blunt type trauma. The rate of posttraumatic empyema development was 3.1% for all patients. Pulmonary contusion was seen in 221 (9.8%) patients and fractures of more than two ribs were seen in 191 (8.4%) patients. Tube thoracostomy placement was performed in the emergency room in 1728 (76.4%) patients, in the hospital ward in 197 (8.7%), in the intensive care unit in 182 (8.0%), and in the operating room in 154 (6.8%). The duration of tube thoracostomy was 6.11 ± 2.99 (1–21) days. Retained haemothorax was seen in 175 (7.7%) patients. The mean lengths of hospital and intensive care unit stay were 6.42 ± 3.45 and 2.36 ± 2.66 days, respectively. The analysis showed that duration of tube thoracostomy (OR, 2.49, p < 0.001), length of intensive care unit stay (OR, 4.21, p < 0.001), and presence of contusion (OR, 3.06, p < 0.001), retained haemothorax (OR, 5.55, p < 0.001), and exploratory laparotomy (OR, 2.46, p < 0.001) were independent predictors of posttraumatic empyema. The relative risk of posttraumatic empyema was higher than 1 for each of the following risk factors: penetrating trauma (OR, 1.59, p = 0.055), associated injuries (OR, 1.12, p = 0.628) and fractures of more than two ribs (OR, 1.60, p = 0.197).

Conclusion
Prolonged duration of tube thoracostomy and length of intensive care unit stay, and the presence of contusion, laparotomy and retained haemothorax are independent predictors of posttraumatic empyema. Use of prophylactic antibiotics may be recommended in patients with these risk factors.

Reporte de Caso: La Primera Colecistectomia NOTES

Report of Transluminal Cholecystectomy in a Human Being
Jacques Marescaux, MD, FRCS; Bernard Dallemagne, MD; Silvana Perretta, MD; Arnaud Wattiez, MD; Didier Mutter, MD, PhD; Dimitri Coumaros, MD
Arch Surg. 2007;142:823-826.

Hypothesis Natural orifice transluminal endoscopic surgery (NOTES) provides the potential for performance of incisionless operations. This would break the physical barrier between bodily trauma and surgery, representing an epical revolution in surgery. Our group at IRCAD-EITS (Institut de Recherche contre les Cancers de l’Appareil Digestif [Institute of Digestive Cancer Research]–European Institute of TeleSurgery) has been actively involved in the development of NOTES since 2004 with a dedicated project created to develop feasibility and survival studies and new endoscopic technology.

Design NOTES cholecystectomy in a woman via a transvaginal approach.

Setting University hospital.

Patient The patient was a 30-year-old woman with symptomatic cholelithiasis.

Intervention The procedure was carried out by a multidisciplinary team using a standard double-channel flexible videogastroscope and standard endoscopic instruments. The placement of a 2-mm needle port, mandatory to insufflate carbon dioxide and to monitor the pneumoperitoneum, was helpful for further retraction of the gallbladder. At no stage of the procedure was there need for laparoscopic assistance. All of the principles of cholecystectomy were strictly adhered to.

Results The postoperative course was uneventful. The patient had no postoperative pain and no scars, and was discharged on the second postoperative day.
Conclusions Transluminal surgery is feasible and safe. NOTES, a radical shift in the practice and philosophy of interventional treatment, is becoming established and is enormously advantageous to the patient. With its invisible mending and tremendous potential, NOTES might be the next surgical evolution.

Incidencia de Embolia Pulmonar Precoz en Trauma

Incidence of Early Pulmonary Embolism After Injury.
Journal of Trauma-Injury Infection & Critical Care. 63(3):620-624, September 2007.

Menaker, Jay; Stein, Deborah; Scalea, Thomas M.

Background: Pulmonary embolism (PE) is a well-recognized potentially fatal complication after trauma. PE is generally thought to occur days after the acute injury. Hypoxia early after injury is often ascribed to other causes. We hypothesized that PE often occurs early after injury and we sought to elucidate the timing of PE after trauma.

Methods: The trauma registry was used to identify all patients diagnosed with an acute PE between June 1999 and December 2004. Medical records were reviewed and demographics, injury specific data, length of stay, comorbidities, and mortality were recorded. Time from injury to diagnosis was recorded as was diagnostic modality and treatment.

Results: In total, 35,424 patients were treated in our trauma center during the study period. Ninety-four patients with PE were identified (0.27%). Mean age was 45 (+/-18.5) years and mean Injury Severity Score was 23 (+/-11.4). Of the total patients, 82% were male and 91.6% sustained blunt trauma. Mean length of stay was 25 (+/-32.1) days. Anatomic areas injured included thorax (37%), lower leg/femur (38%), pelvis/acetabulum (22%), and spine (30%). The diagnosis was confirmed radiographically in 91 patients; two pulmonary emboli were confirmed at autopsy and one, despite a negative CT scan, was treated based on clinical suspicion. Of these 94 patients diagnosed with a PE, the PE was detected by angiogram in 5 (5%), ventilation/perfusion scan in 10 (11%), and computed tomography scan in 76 (81%). PE was diagnosed on day 1 to 4 in 35 patients (37%), on day 5 to 7 in 17 patients (18%), on day 8 to 14 in 22 patients (23%), and after 14 days in 20 patients (21%). Eleven percent died, but only two deaths were attributed to PE.

Conclusion: PE remains relatively common after trauma and occurs in the absence of lower extremity or spinal fractures. Although PE is usually thought to occur between days 5 and 7 after injury, our data suggest that as many as 37% of pulmonary emboli occur early. Clinicians should consider PE in the differential for patients with unexplained hypoxia, even early after injury.

Hiperglicemia Precoz en Trauma Predice Falla Multiorgánica y Muerte Pero No Infección

Early Hyperglycemia Predicts Multiple Organ Failure and Mortality but Not Infection.
Journal of Trauma-Injury Infection & Critical Care. 63(3):487-494, September 2007.
Sperry, Jason; Frankel, Heidi; Vanek, Sue; Nathens, Avery B; Moore, Ernest; Maier, Ronald; Minei, Jospeh.

Background: Previous studies attempting to characterize the association between early hyperglycemia (EH) and subsequent outcome have been performed without utilization of a strict glycemic control protocol. We sought to characterize the clinical outcomes associated with EH in a cohort of severely injured trauma patients, when a strict glycemic control protocol was used.

Methods: Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in blunt injured adults with hemorrhagic shock. Known diabetics and patients with isolated traumatic brain injury were excluded from the analysis. A strict glycemic protocol (target glucose, 80-110 mg/dL) was employed. Cox proportional hazard regression was used to evaluate the effects of EH on multiple organ failure (MOF), nosocomial infection (NI), and mortality, after adjusting for the effects of early death on subsequent infection rates.

Results: Overall mortality, MOF, and NI rates for the entire cohort were 19.6%, 37.5%, and 42.2%, respectively, with a mean Injury Severity Score of 31.6 +/- 14. Cox proportional hazard regression confirmed that EH was independently associated with almost a twofold higher mortality rate and a 30% higher incidence of MOF, but was not an independent risk factor for NI, after controlling for all important confounders. There continued to be no independent association between EH and NI, even when stratified by infection type (pneumonia, catheter-related blood stream infection, or urinary tract infection).

Conclusion: These results suggest that EH is a marker of severe physiologic insult after injury, and that strict glycemic control may reduce or prevent the infectious complications previously shown to be associated with hyperglycemia early after injury.

Estudio COASST: Albumina es Costo-Efectiva en el Manejo de Sepsis Severa

The COASST study: Cost-effectiveness of albumin in severe sepsis and septic shock
Bertrand Guidet, Guillermo Jasso Mosqueda, Gaël Priol and Philippe Aegerte. Université Pierre et Marie Curie-Paris Abstract
Journal of Critical Care Volume 22, Issue 3, September 2007, Pages 197-203

Introduction
The cost-effectiveness of albumin-based fluid support in patients with severe sepsis is not known.

Methods
We compared standard medical practice and systematic albumin infusion. The study population consisted of patients with severe sepsis and/or septic shock admitted to one of the 35 intensive care units belonging to the Cub-Réa regional database between 1 January 1998 and 31 December 2002. Only stays longer than 24 hours and only patients with a minimum of circulatory, renal, or respiratory failure were considered. Cost estimates were based on French diagnosis-related groups and fixed daily prices. A 4.6% reduction in mortality was expected in the albumin arm, as observed in the Saline vs Albumin Fluid Evaluation (SAFE) Study. Life expectancy was estimated with the declining exponential approximation of life expectancy method, based on age, sex, Simplified Acute Physiology Score II, and McCabe score.

Results
The number of lives saved among the 11 137 patients was 513. The average life expectancy of the 5156 patients who left the hospital alive was estimated to be 9.78 years. The costs per life saved and per year life saved were €6037 and €617, respectively. Sensitivity analyses confirmed the robustness of the results.

Conclusion
The application of the SAFE Study results to CUB-Réa data shows that albumin infusion is cost-effective in severe sepsis

Cirugía en Constipación Crónica severa

Artículo publicado en la Revista Chilena de cirugía.

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Depresión: Impacto de Enfermedad Crónica

Depression, chronic diseases, and decrements in health: results from the World Health Surveys
Saba Moussavi, Dr Somnath Chatterji, Emese Verdes, Ajay Tandon, Vikram Patel and Bedirhan Ustun
The Lancet 2007;370:851-8

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Background
Depression is an important public-health problem, and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression, alone or as a comorbidity, on overall health status.

Methods
The WHO World Health Survey (WHS) studied adults aged 18 years and older to obtain data for health, health-related outcomes, and their determinants. Prevalence of depression in respondents based on ICD-10 criteria was estimated. Prevalence values for four chronic physical diseases—angina, arthritis, asthma, and diabetes—were also estimated using algorithms derived via a Diagnostic Item Probability Study. Mean health scores were constructed using factor analysis and compared across different disease states and demographic variables. The relation of these disease states to mean health scores was determined through regression modelling.

Findings
Observations were available for 245 404 participants from 60 countries in all regions of the world. Overall, 1-year prevalence for ICD-10 depressive episode alone was 3·2% (95% CI 3·0–3·5); for angina 4·5% (4·3–4·8); for arthritis 4·1% (3·8–4·3); for asthma 3·3% (2·9–3·6); and for diabetes 2·0% (1·8–2·2). An average of between 9·3% and 23·0% of participants with one or more chronic physical disease had comorbid depression. This result was significantly higher than the likelihood of having depression in the absence of a chronic physical disease (p<0·0001). After adjustment for socioeconomic factors and health conditions, depression had the largest effect on worsening mean health scores compared with the other chronic conditions. Consistently across countries and different demographic characteristics, respondents with depression comorbid with one or more chronic diseases had the worst health scores of all the disease states.

Interpretation
Depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes. The comorbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression. These results indicate the urgency of addressing depression as a public-health priority to reduce disease burden and disability, and to improve the overall health of populations.

Cuando dar Alta en Manejo Conservador del Trauma Esplénico

Early discharge after nonoperative management for splenic injuries: increased patient risk caused by late failure?
Surgery 2007; 142 (3): 337-42
Robert S. Crawford, Malek Tabbara, Robert Sheridan, Konstantinos Spaniolas and George C. Velmahos. Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School.

With increasing experience and knowledge about nonoperative management of splenic injury (NOMSI), patients are being discharged early and possibly placed at risk for late failure of NOMSI and its associated complications. To evaluate if blunt trauma patients managed by NOMSI can be safely discharged early, because failure after the third day from injury occurs infrequently and is not associated with added morbidity.

Methods
The medical records of patients who failed NOMSI from January 1993 to December 2005 in an academic level 1 trauma center were reviewed. Patients who failed NOMSI within 3 days (early failure) were compared with patients who failed it after 3 days (late failure) to identify characteristics that may help predict late failure. Primary outcomes were complications and death related to late failure.

Results
Of 691 patients admitted with blunt trauma to the spleen, 499 (72%) had NOMSI and 36 (7%) failed it. Early failure was recorded in 26 patients (5%) and late failure in 10 (2%). Late bleeding was the cause of failure in all patients with late failure and occurred in 8 ± 6 (mean ± SD) days after admission (4-8 days in 7 patients and 12-22 days in 3). When comparing age, Injury Severity Score, hemotocrit on admission, preoperative blood transfusions, and grade of splenic injury, no differences were found between patients with early and late failure. All but 1 patient with late failure were still in the hospital for associated injuries at the time of failure. No patient died, had delayed diagnosis, or suffered added morbidity because of late failure.

Conclusion
Late failure occurs infrequently, unpredictably, and almost always in patients who are still in the hospital for associated injuries. In-hospital observation beyond the third day after injury is not necessary for most patients with splenic injury, who have no other reason to remain hospitalized.

Cuando Reoperar Tras Realizar Colecistectomía Laparoscópica

Trabajo publicado en el número de septiembre 2007 de Contemporary Surgery el cual abarca el tema de reoperación tras colecistectomía laparoscópica. Muy recomendable su lectura.

PDF inglés.
http://www.contemporarysurgery.com/pdf/6309/6309CS_Review1.pdf

Jornadas de Trauma Vascular

La Sociedad de Cirujanos de Chile presenta "Jornadas de Trauma Vascular". Sin Costo.
Santiago 7 y 8 septiembre. Hotel Neruda.

Programa completo:
http://www.cirujanosdechile.cl/Congresos/PROGRAMA%202007%20Jornadas%20Vasculares.pdf