[Damage control surgery: an update]

Surgical management of complex duodenal trauma using laterolateral duodenum enteroanastomosis: A case report

Introduction and importance

Duodenal trauma is rare, however, it has high morbidity and mortality rates. Surgical treatment modalities are employed depending on severity, ranging from simple sutures to complex pancreaticoduodenectomy cases.

Case presentation

A male patient had a circular saw accident, leading to evisceration in an extensive wound from the thoracoabdominal transition to the inguinal region, with 75% laceration of the second duodenal portion circumference, laceration in hepatic segments, section from right mesocolon to transverse colon, and multiple perforations in small bowel loops between 70 and 90 cm from the angle of Treitz. Laterolateral duodenum enteroanastomosis was performed with proximal jejunum and gastroenteroanastomosis with the distal loop of the small intestine at 90 cm from the Treitz angle, and a termino lateral enteroanastomosis between food and the biliary loop at 20 cm from the gastroenteroanastomosis.

Clinical discussion

This report presents a new surgical technique for patients with penetrating duodenal trauma associated with liver and intestinal injuries, to avoid the need for more complex procedures. In addition, it demonstrates postoperative management of complications, including confection of the enteroatmospheric fistula for feeding.

Conclusion

The technique described in this article proved to be a good option for treating these lesions, as evidenced by optimal postoperative results.

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Duodenal lesions are challenging to repair due to presentation heterogeneity.

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The use of this new technique proved to be a safe alternative.

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Despite the complex trauma, the patient evolved well.

Splenic implant preservation after conservation in lactated Ringer´s solution

OBJECTIVE

to evaluate the morphology and function of autogenous splenic tissue implanted in the greater omentum, 24 hours after storage in Ringer-lactate solution.

METHODS

we divided 35 male rats into seven groups (n=5): Group 1: no splenectomy; Group 2: total splenectomy without implant; Group 3: total splenectomy and immediate autogenous implant; Group 4: total splenectomy, preservation of the spleen in Ringer-lactate at room temperature, then sliced ​​and implanted; Group 5: total splenectomy, ​​spleen sliced and preserved in Ringer-lactate at room temperature before implantation; Group 6: total splenectomy with preservation of the spleen in Ringer-lactate at 4°C and then sliced ​​and implanted; Group 7: total splenectomy and the spleen sliced for preservation in Ringer-lactate at 4°C before implantation. After 90 days, we performed scintigraphic studies with Tc99m-colloidal tin (liver, lung, spleen or implant and clot), haematological exams (erythrogram, leucometry, platelets), biochemical dosages (protein electrophoresis) and anatomopathological studies.

RESULTS

regeneration of autogenous splenic implants occurred in the animals of the groups with preservation of the spleen at 4ºC. The uptake of colloidal tin was higher in groups 1, 3, 6 and 7 compared with the others. There was no difference in hematimetric values ​​in the seven groups. Protein electrophoresis showed a decrease in the gamma fraction in the group of splenectomized animals in relation to the operated groups.

CONCLUSION

the splenic tissue preserved in Ringer-lactate solution at 4ºC maintains its morphological structure and allows functional recovery after being implanted on the greater omentum.

Comparative study of abdominal cavity temporary closure techniques for damage control

The damage control surgery, with emphasis on laparostomy, usually results in shrinkage of the aponeurosis and loss of the ability to close the abdominal wall, leading to the formation of ventral incisional hernias. Currently, various techniques offer greater chances of closing the abdominal cavity with less tension. Thus, this study aims to evaluate three temporary closure techniques of the abdominal cavity: the Vacuum-Assisted Closure Therapy - VAC, the Bogotá Bag and the Vacuum-pack. We conducted a systematic review of the literature, selecting 28 articles published in the last 20 years. The techniques of the bag Bogotá and Vacuum-pack had the advantage of easy access to the material in most centers and low cost, contrary to VAC, which, besides presenting high cost, is not available in most hospitals. On the other hand, the VAC technique was more effective in reducing stress at the edges of lesions, removing stagnant fluids and waste, in addition to acting at the cellular level by increasing proliferation and cell division rates, and showed the highest rates of primary closure of the abdominal cavity. RESUMO A cirurgia de controle de danos, com ênfase em peritoneostomia, geralmente resulta em retração da aponeurose e perda da capacidade de fechar a parede abdominal, levando à formação de hérnias ventrais incisionais. Atualmente, várias técnicas oferecem maiores chances de fechamento da cavidade abdominal, com menor tensão. Deste modo, este estudo tem por objetivo avaliar três técnicas de fechamento temporário da cavidade abdominal: fechamento a vácuo (Vacuum-Assisted Closure Therapy - VAC), Bolsa de Bogotá e Vacuum-pack. Realizou-se uma revisão sistemática da literatura com seleção de 28 artigos publicados nos últimos 20 anos. As técnicas de Bolsa de Bogotá e Vacuum-pack tiveram como vantagem o acesso fácil ao material, na maioria dos centros, e baixo custo, ao contrário do que se observa na terapia a vácuo, VAC, que além de apresentar alto custo, não está disponível em grande parte dos hospitais. A técnica VAC, por outro lado, foi mais eficaz na redução da tensão nas bordas das lesões, ao remover fluidos estagnados e detritos, além de exercer ação a nível celular, aumentando as taxas de proliferação e divisão celular, e apresentou as maiores taxas de fechamento primário da cavidade abdominal.

LIVER TRANSPLANTATION AFTER SEVERE HEPATIC TRAUMA: CURRENT INDICATIONS AND RESULTS

Background :

The liver is the most injured organ in abdominal trauma. Currently, the treatment in most cases is non-operative, but surgery may be necessary in severe abdominal trauma with blunt liver damage, especially those that cause uncontrollable bleeding. Despite the damage control approaches in order to achieve hemodynamic stability, many patients develop hypovolemic shock, acute liver failure, multiple organ failure and death. In this context, liver transplantation appears as the lifesaving last resource

Aim :

Analyze the use of liver transplantation as a treatment option for severe liver trauma.

Methods :

Were reviewed 14 articles in the PubMed, Medline and Lilacs databases, selected between 2008-2014 and 10 for this study.

Results :

Were identified 46 cases undergoing liver transplant after liver trauma; the main trauma mechanism was closed/blunt abdominal trauma in 83%, and severe trauma (>grade IV) in 81 %. The transplant can be done, in this context, performing one-stage procedure (damaged organ removed with immediate transplantation), used in 72% of cases. When the two-stage approach is performed, end-to-side temporary portacaval shunt is provided, until new organ becomes available to be transplanted. If two different periods are considered - from 1980 to 2000 and from 2000 to 2014 - the survival rate increased significantly, from 48% to 76%, while the mortality decreased from 52% to 24%.

Conclusion :

Despite with quite restricted indications, liver transplantation in hepatic injury is a therapeutic modality viable and feasible today, and can be used in cases when other therapeutic modalities in short and long term, do not provide the patient survival chances.

Floating stoma: An alternative strategy in the context of damage control surgery

INTRODUCTION

Floating stoma (FS) is a strategy to be considered in the context of damage control surgery (DCS). The purpose of this study is to describe the technique used and the results of a series of patients where FS was used.

METHODS

Case series of relaparotomized patients at two emergency services in Temuco, Chile (2005-2014). In all of them, once drainage of septic focus or damage was controlled, the abdomen was left open with a Bogota bag (BB) and FS. Outcome variables were FS indications, morbidity, time to first replacement of BB, definitive maturation of the stoma (DMS), time to withdraw the BB and mortality.

RESULTS

FS was performed in 46 patients with a mean age of 49.3±21.1 years; 63% were female. The indication of FS was abdominal sepsis by secondary peritonitis (69.6%), abdominal trauma (17.4%), and mesenteric ischemia (13.0%). Morbidity was 37.0%. Median time to first replacement of BB, DMS and time to withdraw the BB were 84hours, 3.5 days and 49 days, respectively. Mortality was 19.6%.

CONCLUSION

FS is a temporary resource reserved for special surgical cases. It is associated with morbidity and mortality inherent with the severity of the patients on whom it can be used.