Trauma of pancreas of pancreas : predictive factors of morbidity and mortality related to trauma index

Orientadores: Mario Mantovani, Gustavo Pereira FragaTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Embora incomuns, lesões traumáticas do pâncreas estão associadas a significativos níveis de complicações e mortalidade. O objetivo deste estudo foi definir os fatores preditivos de morbidade e mortalidade em pacientes vítimas de trauma pancreático. Nesta casuística, foram estudados 131 pacientes atendidos pela Disciplina de Cirurgia do Trauma no Hospital de Clínicas da UNICAMP no período entre janeiro de 1994 a dezembro de 2007, com seus parâmetros epidemiológicos, fisiológicos e anatômicos registrados em protocolo específico prospectivamente e, comparados e analisados aos fatores preditivos de evolução, com estudo estatístico. Trauma penetrante, com predomínio de ferimentos por projétil de arma de fogo ocorreu em 64% dos casos. A maioria, 91,6% era do sexo masculino e a idade média de 29,8 anos. A morbidade global foi de 64,9%, com 29% de complicações diretamente relacionadas ao pâncreas, como fístulas e sangramento. A mortalidade foi de 27,5%, principalmente em decorrência de choque hipovolêmico e falência de múltiplos órgãos e sistemas. Houve maior morbidade e mortalidade em pacientes com lesões complexas (graus IV e V) do pâncreas quando comparados com lesões menos graves (graus I e II), porém a morbidade e mortalidade neste grupo não foi desprezível, devido a valores alterados de RTS, valores elevados de ISS e ATI. Pacientes com valores alterados de RTS, pressão arterial sistólica menor que 90 mmHg, valor de ISS maior ou igual a 25 e valor de ATI maior ou igual a 25 apresentaram maior incidência de complicações mórbidas e maior mortalidade. Pacientes com valores elevados de TRISS ainda apresentaram complicações mórbidas e óbito. O presente estudo conclui que lesões complexas do pâncreas, pressão aterial sistólica inferior a 90 mm Hg, RTS com valor alterado, ISS maior ou igual a 25 e ATI maior ou igual a 25 são preditivos de maior morbidade e mortalidade em pacientes traumatizados com lesão pancreáticaAbstract: Although uncommon, traumatic pancreatic injury is associated with significative index of morbidity and mortality. The objective of the study was to define the predictors' factors of increase in the morbidity and mortality in patients with pancreatic trauma. In this casuistic 131 patients were studied, since January 1994 through December 2007, with theirs epidemiological, physiological and anatomic parameters compared and the analysis of the predictive values for the occurrence of bad evolution, with an appropriate statistical study. Prospective coorte study. Penetrating trauma occurred in 64% and blunt trauma in 36%, and 91,6% was male. The mean age was 29,8 years.The global morbidity in this series was 64,9% with 29% prevalence of pancreas related complications, such as pancreatic fistula and bleeding occurrence. The overall mortality was 27,5% and occurred by hemorrhagic shock and multiple organs and system failed. Higher morbidity and mortality was related with complex injuries of the pancreas (grade IV and V), but morbidity and mortality in the group of injuries grade I and II are not minimal in patients with changed values of RTS and high values of ISS and ATI. Systolic blood pressure lower 90 mmHg, changed values of RTS index, values of ISS higher 25 and values of ATI higher 25 are predictive factors of morbidity and mortality. This study conclude complex injuries of pancreas, systolic blood pressure lower 90 mmHg, changed values of RTS, values of ISS and ATI higher 25 are predictive factors of elevation morbidity and mortalityDoutoradoCirurgiaCirurgi

Avaliação das lesões teciduais hepaticas durante isquemia fria apos perfusão com analogo de prostaglandina E1 : estudo experimental em ratos

Orientador: Luiz Sergio LeonardiDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Foi estudado o efeito de análogo de prostaglandina El sobre as lesões teciduais hepáticas que ocorrem durante o período de isquemia fria com o objetivo de verificar se sua utilização em solução de perfusão proporciona maior proteção ao parênquima hepático. Utilizou-se 30 ratos machos, divididos em dois grupos: controle, perfundido com solução de WISCOnsin e o segundo grupo perfundido com solução de Wisconsin acrescida de análogo de prostaglandina El (misoprostol). Foram colhidas biópsias imediatamente após a perfusão e depois com intervalos de 12, 18 e 24 horas após a perfusão. As variáveis estudadas em cada biópsia foram edema intersticial, degeneração hidrópica, degeneração gordurosa, lesão endotelial, lesão do epitélio biliar, necrose celular e infiltrado inflamatório. Essas variáveis foram comparadas em cada grupo com o teste de Mann-Whitney, para variáveis não paramétricas. Nos períodos de 12 e 18 horas não observou-se diferença significativa em nenhuma variável entre os grupos. No período de 24 horas foi observado uma diferença significativa (p<0,001) nas variáveis necrose celular, lesão endotelial e infiltrado inflamatório. Conclui-se que a utilização de análogo de prostaglandina E 1 na perfusão hepática confere proteção ao tecido hepático quando submetido a um período de isquemia mais prolongadoAbstract: The effect of prostaglandin El analogue in hepatic injury during cold ischenúa were evalueted in this study. The objective to verifY if occur attenuation in the ischemic liver damage. Thirty male rats were divided in two groups of 15 animaIs each: control, where was perfunded with University of Wisconsin solution and test group, which was perfunded with this solution added of prostaglandin El analogue (misoprostol). Biopsies were obtained immediately after perfusion and with 12, 18 and 24 hours after the perfusion. The variables analysed were tissular edema, hidropic changes, fatty changes, endothelium injury, bile duct injury, necrosis and inflammatory processo The Mann- Whitney test for non-parametric variables was used to compare the samples. In the period of 12 and 18 hours no statistical difIerences were found in biopsies. In the period of 24 hours necrosis, endothelium injury and inflammatory process were significant1y more (p < 0,001) in control group. The author conc1ued that utilization of prostaglandin E 1 analogue in hepatic perfusion has a protective effect ofhepatic tissue injury during prolongated storage. The effect of prostaglandin El analogue in hepatic injury during cold ischenúa were evalueted in this study. The objective to verifY if occur attenuation in the ischemic liver damage. Thirty male rats were divided in two groups of 15 animaIs each: control, where was perfunded with University of Wisconsin solution and test group, which was perfunded with this solution added of prostaglandin El analogue (misoprostol). Biopsies were obtained immediately after perfusion and with 12, 18 and 24 hours after the perfusion. the variables analysed were tissular edema, hidropic changes, fatty changes, endothelium injury, bile duct injury, necrosis and inflammatory processo The Mann- Whitney test for non-parametric variables was used to compare the samples. In the period of 12 and 18 hours no statistical difIerences were found in biopsies. In the period of 24 hours necrosis, endothelium injury and inflammatory process were significant1y more (p < 0,001) in control group.The author conc1ued that utilization of prostaglandin E 1 analogue in hepatic perfusion has a protective effect ofhepatic tissue injury during prolongatedstorageMestradoCirurgiaMestre em Cirurgi

Use of Sengstaken-Blakemore Intrahepatic Balloon: An Alternative for Liver-Penetrating Injuries

Severe lesions in the liver are associated with a high mortality rate. Alternative surgical techniques such as the use of an intrahepatic balloon may be effective and reduce mortality in severe hepatic lesions. This study aimed to demonstrate the experience of a university hospital in the use of the Sengstaken-Blakemore balloon in patients with transfixing penetrating hepatic injury as an alternative way to treat these challenging injuries. A retrospective study based on the trauma registry of a university hospital was performed. All patients admitted with hepatic penetrating injuries and treated with the Sengstaken-Blakemore balloon within the period 1990-2010 were reviewed. Forty-six patients with transfixing hepatic injuries were treated with the Sengstaken-Blakemore balloon in the study period. The most frequent cause of injury was gunshot wound (87 % of the patients). The mean trauma scores on admission were Revised Trauma Score (RTS) = 7.12 +/- A 1.46, Injury Severity Score (ISS) = 22.4 +/- A 9.7, and Abdominal Trauma Index (ATI) = 19.5 +/- A 11. According to the severity of the hepatic trauma, 71.8 % of patients had grade III, 23.9 % grade IV, and 4.3 % grade V injuries. Associated abdominal injuries were found in 89.1 % of the patients. The most frequent liver-related complications were hepatic abscess postoperative bleeding (8.6 %), biliary fistula (8.6 %), (4.3 %), and biliary peritonitis (2.1 %). Surgical reintervention was necessary in 14 patients (31.1 %). From those 14, only 3 had the balloon removed. The overall morbidity and mortality rates were 56.5 % and 23.9 % (11 patients), respectively. The knowledge of alternative surgical techniques is essential in improving survival in patients with severe penetrating hepatic injuries. The use of intrahepatic balloon is a viable surgical strategy.3692119212

Use of sengstaken-blakemore intrahepatic balloon : an alternative for liver-penetrating injuries

Severe lesions in the liver are associated with a high mortality rate. Alternative surgical techniques such as the use of an intrahepatic balloon may be effective and reduce mortality in severe hepatic lesions. This study aimed to demonstrate the experience of a university hospital in the use of the Sengstaken-Blakemore balloon in patients with transfixing penetrating hepatic injury as an alternative way to treat these challenging injuries. A retrospective study based on the trauma registry of a university hospital was performed. All patients admitted with hepatic penetrating injuries and treated with the Sengstaken-Blakemore balloon within the period 1990–2010 were reviewed. Forty-six patients with transfixing hepatic injuries were treated with the Sengstaken-Blakemore balloon in the study period. The most frequent cause of injury was gunshot wound (87 % of the patients). The mean trauma scores on admission were Revised Trauma Score (RTS) = 7.12 ± 1.46, Injury Severity Score (ISS) = 22.4 ± 9.7, and Abdominal Trauma Index (ATI) = 19.5 ± 11. According to the severity of the hepatic trauma, 71.8 % of patients had grade III, 23.9 % grade IV, and 4.3 % grade V injuries. Associated abdominal injuries were found in 89.1 % of the patients. The most frequent liver-related complications were hepatic abscess postoperative bleeding (8.6 %), biliary fistula (8.6 %), (4.3 %), and biliary peritonitis (2.1 %). Surgical reintervention was necessary in 14 patients (31.1 %). From those 14, only 3 had the balloon removed. The overall morbidity and mortality rates were 56.5 % and 23.9 % (11 patients), respectively. The knowledge of alternative surgical techniques is essential in improving survival in patients with severe penetrating hepatic injuries. The use of intrahepatic balloon is a viable surgical strategy3692119212