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Resumen Introduccion La localizacion anatomica de las heridas por arma blanca (HAB) penetrantes en abdomen y su relacion con el manejo selectivo no operatorio (MSNO) tiene escaso reflejo en la literatura especializada. Nuestro objetivo principal ha sido valorar la tasa de MSNO en funcion de esa localizacion anatomica, y sus resultados. Metodos Revision retrospectiva del registro prospectivo de trauma abdominal desde abril de 1993 hasta junio de 2020. Los dos grupos a estudio fueron manejo operatorio (MO) y MSNO, incluyendo en este ultimo grupo el uso de laparoscopias exploradoras como metodo diagnostico. Se clasificaron las HAB penetrantes en abdomen en funcion de su localizacion anatomica. Resultados Identificamos 259 pacientes que cumplian los criterios de inclusion. El MSNO se aplico en el 31% de los pacientes, con una tasa de exito del 96,5%. En las HAB de las regiones lumbares, flancos y toracoabdominales fue donde se opto mas frecuentemente por este manejo; y en el abdomen anterior fue mas aplicable en el hipocondrio derecho (HD), seguido del hipocondrio izquierdo (HI) y epigastrio. Se realizo una laparotomia innecesaria en el 21%, con la cifra mas alta en el epigastrio. Teniendo en cuenta los porcentajes de MSNO y laparotomias evitables en cada region, el 70,5% de las HAB lumbares, el 66,5% de las epigastricas, el 62% de flancos y el 59% de HD se podrian haber manejado con exito sin laparotomia. Conclusiones El MSNO de las HAB penetrantes en abdomen ha resultado mas seguro y aplicable en las localizadas en las regiones lumbares, flancos, epigastrio e HD.

BACKGROUND The aim was to evaluate the relevance of pneumoperitoneum on the success rate of non-operative management (NOM) of patients with complicated acute diverticulitis (AD), and the risk factors associated with failure. METHODS Observational retrospective cohort study of patients attended at the emergency department for AD from January 2015-August 2019. Patient demographics, blood tests, radiological data and initial treatment strategies were registered. NOM, based on intravenous antibiotics (ATB) and bowel rest, was defined as unsuccessful when emergency surgery (ES) and/or infection-related death took place. Patients initially treated with ES were excluded. Analysis was done with the IBM SPSS statistics 23.0.0.2 software. RESULTS According to modified Hinchey and WSES criteria, 99 (12%) of 826 AD episodes were complicated, with pneumoperitoneum on the CT scan in 89 (90.5%). NOM was undertaken in 93 (94%) cases, with a 91.5% success rate. Multivariate analysis revealed ASA class III-IV, and the presence of fluid collections >3cm in diameter, but not distant free air, to be associated with NOM failure. However, the success rate of NOM was significantly higher in patients with pericolic pneumoperitoneum (98.5%) than in those with distant free air (80%) (p=0.02). Risk factors of NOM failure were an advanced age, high CRP and WBC values, and the presence of free fluid in >2 abdominal quadrants. CONCLUSIONS NOM in hemodynamically stable patients with complicated AD is a safe and feasible approach, even in the context of distant free air. Nevertheless, patients with isolated pericolic air did better in our series.

Resumen Introduccion El tratamiento de las fracturas de pelvis con hematoma retroperitoneal (HRP) es controvertido. Especialmente la necesidad de angioembolizacion (AE) cuando no hay extravasacion de contraste (EC) en la tomografia computarizada (TC) o angiografia. Otro aspecto relevante es el retraso hasta la misma. Nuestro objetivo ha sido determinar si existen diferencias en el tiempo hasta la AE entre los pacientes admitidos durante el horario laboral y los admitidos fuera del mismo y durante los fines de semana y festivos. Nuestra hipotesis era que la angiografia y AE serian mas frecuentes en el horario laboral, y el tiempo hasta las mismas seria superior fuera del horario laboral habitual, con una mortalidad mayor en este grupo para una gravedad global similar. Un objetivo secundario ha sido valorar la correlacion entre EC en la TC y la angiografia. Metodos Analisis retrospectivo de 2 cohortes de pacientes con HRP por fractura de pelvis. Se estudia la realizacion de angiografia dividiendo a los pacientes segun su hora de llegada a lo largo de un periodo de 24 anos (grupo A: horario laboral, y grupo B: fuera del mismo). La indicacion de angiografia y AE fue realizada por la guardia de cirugia general, en consenso con el radiologo intervencionista. Se han analizado variables demograficas, mecanismo lesivo, lesiones asociadas, gravedad fisiologica y anatomica, EC en la TC y la angiografia, necesidad de AE, estancia en unidad de cuidados intensivos (UCI) y mortalidad. Resultados Se admitio a 104 pacientes con diagnostico de HRP por fractura pelvica. Se realizo angiografia, con AE en 63 casos (61%). Los grupos eran comparables en las variables analizadas. En el 70% de los pacientes del grupo A se realizo angiografia, frente al 57% del grupo B, sin diferencias en tiempo hasta la AE. Se demostro EC en la TC en 53 de los 96 pacientes en los que se hizo, lo que se confirmo mediante angiografia en el 85%. No hubo diferencias estadisticamente significativas de mortalidad entre ambos grupos. Conclusiones Se demuestra un tiempo corto entre la admision en Urgencias y la AE, sin relacion con el momento del ingreso durante el dia, y una buena correlacion entre la EC en la TC y la angiografia.

The relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results.Retrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location.We identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RUQ, followed by the LUQ and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70,5% of lumbar, el 66,5% of epigastric, 62% of flank, and 59% of RUQ penetrating SWs could have been managed without a laparotomy.SNOM of penetrating SWs in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RUQ regions.

New coronavirus SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) has determined the necessity of reorganization in many centers all over the world. Spain, as an epicenter of the disease, has been forced to assume health policy changes in all the territory. However, and from the beginning of the pandemic, every center attending surgical urgencies had to guarantee the continuous coverage adopting correct measures to maintain the excellence of quality of care. This document resumes general guidelines for emergency surgery and trauma care, obtained from the available bibliography and evaluated by a subgroup of professionals designated from the general group of investigators Cirugia-AEC-COVID-19 from the Spanish Association of Surgeons, directed to minimize professional exposure, to contemplate pandemic implications over different urgent perioperative scenarios and to adjust decision making to the occupational pressure caused by COVID-19 patients.

The Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management was formulated in Germany by military medical personnel, who have been deployed to conflict areas, but also work in hospitals open for the lay public. In this manuscript we discuss different concepts and ideas taught in this course as these are described in a focused issue recently published in the European Journal of Trauma and Emergency Surgery. We provide reinforcement for some of the ideas conveyed. We provide alternative views for others. Injuries following explosions are different from blunt and penetrating trauma and at times demand a different approach. There are probably several ways to manage a mass casualty incident depending on the setup of the organization. An open discussion on the topics presented in the manuscripts included in the focused issue on military and disaster surgery should enrich everyone.

Specific training in the management of trauma patients is beneficial for surgeons. Training through specific courses in this area has a direct impact on the care of these patients. The aim of this work is to understand the participation and specific training in the care of trauma patients by Spanish surgeons. A national survey was conducted and administered to all members of the Spanish Association of Surgeons. The survey assessed their degree of participation in emergency surgery, and therefore the probability of attending trauma patients, their assessment of the initial care of trauma patients in their centre, and their specific training in this field. The survey was completed by 510 surgeons from 47 Spanish provinces, with Catalonia and Andalusia being the most represented regions. In total, 456 (89.41%) of those surveyed work in the emergency department on a routine basis. Only 171 (33.53%) refer to having a registry of trauma patients in their hospital. While 79.02% of surgeons reported that general surgeons are not involved in care of severe trauma from the outset, only 66.47% have completed the ATLS course, 40.78% the DSTC course and 18.82% the MUSEC course. Despite this, 85.69% believe that the ATLS course should be compulsory during residency and 43.33% believe that severe trauma care in their hospital is poor or very poor. Only 40% have received specific training in definitive surgical management of severe trauma. Despite this, a large percentage of surgeons work in the emergency department on a routine basis and potentially face the challenge of managing these patients.

Resumen El modelo Acute Care Surgery agrupa bajo una misma disciplina el trauma, la cirugia de urgencias y los cuidados intensivos posquirurgicos. Concebido y extendido durante las 2 ultimas decadas por territorio norteamericano, la magnitud e idiosincrasia clinica de la urgencia quirurgica han hecho que este modelo se haya asumido en muchos otros puntos de la geografia mundial. En nuestro pais, el reflejo ha sido la creacion e implantacion de las denominadas unidades de trauma y cirugia de urgencias, cuyos objetivos son comunes a las publicadas para el modelo original: evitar la nocturnidad en las urgencias quirurgicas, liberar a los profesionales vinculados a la cirugia electiva en horario laboral y convertirse en el eslabon y referente perfectos de la continuidad asistencial. En el presente articulo se resumen el nacimiento y la expansion del modelo original, la evidencia aportada en cuanto a resultados y la situacion actual en nuestro pais.

Resumen Diversos cambios introducidos en la atencion al paciente traumatizado en las dos ultimas decadas han hecho disminuir considerablemente la exposicion practica al manejo de las lesiones viscerales y hemorragicas por parte de los MIR y cirujanos jovenes. Esta hemorragia sigue siendo la segunda causa de muerte por trauma a nivel mundial, y determinadas maniobras quirurgicas necesarias para su control adquieren a menudo una importancia critica, debiendo ser aprendidas y ensayadas en cursos especificos. Son cursos dirigidos a la «segunda hora», mas alla del ATLS©, y enfatizan tambien el proceso de toma de decisiones, discusion de casos clinicos y comunicacion entre los miembros del equipo multidisciplinar. Los avances significativos experimentados en las tecnologias de simulacion y los sistemas de realidad virtual no han logrado aun reemplazar a los modelos tisulares vivos para entrenar al cirujano en el control del sangrado activo de una manera rapida, aunque sin duda lo haran en un futuro no lejano.

Several changes introduced in the management of trauma during the last two decades have considerably decreased the practical exposure to bleeding trauma patients by residents and young surgeons. Hemorrhage still represents the second cause of death from trauma worldwide, and the surgical maneuvers required for its control must be learned and practised in specific courses. These courses address the "second hour" of trauma, beyond ATLS©, and also emphasize the decision-making process, communication among team members, and discussion of clinical scenarios. The significant progress made in simulation technologies and virtual reality systems have yet to replace living tissue models to train surgeons in the rapid control of active bleeding, although that replacement is probably not far away.

Background In mass casualty incidents (MCI), death usually occurs within the first few hours and thus early transfer to a trauma centre can be crucial in selected cases. However, most triage systems designed to prioritize the transfer to hospital of these patients do not assess the need for surgery, in part due to inconclusive evidence regarding the value of such an assessment. Therefore, the aim of the present study was to evaluate the capacity of a new triage system—the Prehospital Advanced Triage Method (META)—to identify victims who could benefit from urgent surgical assessment in case of MCI. Methods Retrospective, descriptive, observational study of a multipurpose cohort of patients included in the severe trauma registry of the Gregorio Marañón University General Hospital (Spain) between June 1993 and December 2011. All data were prospectively evaluated. All patients were evaluated with the META system to determine whether they met the criteria for urgent transfer. The META defines patients in need of urgent surgical assessment: (a) All penetrating injuries to head, neck, torso and extremities proximal to elbow or knee, (b) Open pelvic fracture, (c) Closed pelvic fracture with mechanical or haemodynamic instability and (d) Blunt torso trauma with haemodynamic instability. Patients who fulfilled these criteria were designated as “Urgent Evacuation for Surgical Assessment” (UESA) cases; all other cases were designated as non-UESA. The following variables were assessed: patient status at the scene; severity scales [RTS, Shock index, MGAP (Mechanism, Glasgow coma scale, Age, pressure), GCS]; need for surgery and/or interventional procedure to control bleeding (UESA); and mortality. The two groups (UESA vs. non-UESA) were then compared. Results A total of 1882 cases from the database were included in the study. Mean age was 39.2 years and most (77%) patients were male. UESA patients presented significantly worse on-scene hemodynamic parameters (systolic blood pressure and heart rate) and greater injury severity (RTS, shock index, and MGAP scales). No differences were observed for respiratory rate, need for orotracheal intubation, or GCS scores. The anatomical injuries of patients in the UESA group were less severe but these patients had a greater need for urgent surgery and higher mortality rates. Conclusion These findings suggest that the META triage classification system could be beneficial to help identify patients with severe trauma and/or in need of urgent surgical assessment at the scene of injury in case of MCI. These findings demonstrate that, in this cohort, the META fulfils the purpose for which it was designed. Sin financiación 3.693 JCR (2020) Q1, 6/32 Emergency Medicine 0.641 SJR (2020) Q2, 30/88 Critical Care and Intensive Care Medicine No data IDR 2020 UEM

Extremities are commonly injured following bomb explosions. The main objective of this study was to evaluate the prevalence of hemorrhagic shock (HS) in victims of explosion suffering from extremity injuries. Retrospective study based on a cohort of patient records maintained in one hospital’s mass casualty registry. Sixty-six victims of explosion who were hospitalized with extremity injuries were identified and evaluated. Sixteen (24.2%) of these were hemodynamically unstable during the first 24 h of treatment. HS could be attributed to associated injuries in seven of the patients. In the other nine patients, extremity injury was the only injury that could explain HS in seven patients and the extremity injury was a major contributor to HS together with another associated injury in two patients. In those 9 patients, in whom the extremity injury was the sole or major contributor to HS, a median of 10 (range 2–22) pRBC was transfused during the first 24 h of treatment. Six of the nine patients were in need of massive transfusion. Fractures in both upper and lower extremities, Gustilo IIIb-c open fractures and AIS 3–4 were found to be risk factors for HS. Ample consideration should be given to patients with extremity injuries due to explosions, as these may be immediately life threatening. Tourniquet use should be encouraged in the pre-hospital setting. Before undertaking surgery, emergent HS should be considered in these patients and prevented by appropriate resuscitation.

espanolLa hidatidosis hepatica tiene una forma clinica de presentacion muy variada desde una enfermedad asintomatica hasta formas muy graves como el shock anafilactico. Ademas, el abordaje laparoscopico de la enfermedad hepatica esta en auge ya que combina los mismos resultados erradicadores de la cirugia abierta con las ventajas de la cirugia minimamente invasiva. Presentamos el caso de una paciente que debuto con un episodio de fibrilacion auricular secundaria a un derrame pericardico por un quiste hidatidico hepatico complicado. Mediante el abordaje laparoscopico, se dreno el absceso subfrenico y se realizo una periquistectomia parcial y una omentoplastia. La paciente fue dada de alta el cuarto dia postoperatorio y permanece asintomatica 3 anos despues, sin evidencia de fibrilacion auricular o recidiva hidatidica.La fibrilacion auricular es una presentacion extraordinaria de la hidatidosis hepatica. Si bien el abordaje laparoscopico parece seguro y factible en estos pacientes, se necesitan mas estudios para demostrar que es una alternativa segura, con menos dolor postoperatorio y menor estancia hospitalaria. hospitalaria. EnglishHydatid cyst disease has a wide clinical spectrum which goes from a silent disease to severe forms such as anaphylactic shock. In addition, laparoscopic approach to the liver is on the rise as it combines the same results of open surgery with the advantages of minimally invasive surgery. We report the case of a female patient who presentated an episode of atrial fibrillation secondary to a pericardial effusion from a complicated hepatic hydatid cyst. Through laparoscopic approach the subphrenic abscess was drained, and a partial peri-cystectomy and omentoplasty was performed. The patient was discharged on the 4th postoperative day, and she remains asymptomatic 3 years later, with no evidence of atrial fibrillation or hydatic recurrence. Atrial fibrillation is an extraordinary presentation of hepatic hydatidosis. Although the laparoscopic approach seems safe and feasible in these patients, more studies are needed to demonstrate that it is a safe alternative, with less postoperative pain and shorter hospital stay.

IntroductionTrauma patients in the extremes of age may require a specialized approach during a multiple-casualty incident (MCI).ProblemThe aim of this study was to examine the type of injuries encountered in children and elderly patients and the implications of these injuries for treatment and organization.MethodsA review of medical record files of patients admitted in MCIs in one Level II trauma center was conducted. Patients were classified according to age: children (≤12 years), adults (between 12-65 years), and elders (≥65 years).ResultsThe files of 534 were screened: 31 (5.8%) children and 54 (10.1%) elderly patients. One-third of the elderly patients were either moderately or severely injured, compared to only 6.5% of the children and 11.1% of the adults (PConclusionsInjury at an older age confers an increased risk of complications and death in victims of MCIs.AshkenaziI, EinavS, OlshaO, Turegano-FuentesF, KrauszMM, AlficiR. The impact of age upon contingency planning for multiple-casualty incidents based on a single center’s experience. Prehosp Disaster Med. 2016;31(5):492–497.

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

Introduction Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3 pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography. Methods Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality. Results 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups. Conclusions There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography.

Resumen Objetivos La gangrena de Fournier (GF) es la fascitis necrosante del perine y area genital que presenta una elevada mortalidad. El objetivo es analizar los factores pronosticos de mortalidad, creacion de una nueva escala predictiva de mortalidad y compararla con las ya validadas en los pacientes diagnosticados de GF en nuestro Servicio de Urgencias. Metodos Estudio analitico, retrospectivo entre 1998 y 2012. Resultados De los 59 casos, 44 sobrevivieron (74%) (S) y 15 fallecieron (26%) (E). Se encontraron diferencias significativas en la vasculopatia periferica (S 5 [11%]; E 6 [40%]; p = 0,023), hemoglobina (S 13; E 11; p = 0,014), hematocrito (S 37; E 31,4; p = 0,009), leucocitos (S 17.400; E 23.800; p = 0,023), urea (S 58; E 102; p Conclusiones La GF presento una tasa de mortalidad elevada cuyos factores predictores independientes fueron la vasculopatia periferica, el potasio serico y criterios de sepsis grave, creando un modelo con una capacidad discriminativa superior al resto.

Aims Fournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area and presents a high mortality rate. The aim was to assess prognostic factors for mortality, create a new mortality predictive scale and compare it with previously published scales in patients diagnosed with FG in our Emergency Department. Methods Retrospective analysis study between 1998 and 2012. Results Of the 59 patients, 44 survived (74%) (S) and 15 died (26%) (D). Significant differences were found in peripheral vasculopathy (S 5 [11%]; D 6 [40%]; P = .023), haemoglobin (S 13; D 11; P = .014), haematocrit (S 37; D 31.4; P = .009), white blood cells (S 17,400; D 23,800; P = .023), serum urea (S 58; D 102; P = .001), creatinine (S 1.1; D 1.9; P = .032), potassium (S 3.7; D 4.4; P = .012) and alkaline phosphatase (S 92; D 133; P = .014). Predictive scores were: Charlson index (S 1; D 4; P = .013), severe sepsis criteria (S 16 [36%]; D 13 [86%]; P = .001), Fournier's Gangrene Severity Index Score (FGSIS) (S 4; D 7; P = .002) and Uludag Fournier's Gangrene Severity Index (UFGSI) (S 9; D 13; P = .004). Independent predictive factors were peripheral vasculopathy, serum potassium and severe sepsis criteria, and a model was created with an area under the ROC curve of 0.850 (0.760–0.973), higher than FGSIS (0.746 [0.601–0.981]) and UFGSI (0.760 [0.617–0.904]). Conclusions FG showed a high mortality rate. Independent predictive factors were peripheral vasculopathy, potassium and severe sepsis criteria creating a predictive model that performed better than those previously described.

The unique patterns of injury following explosions together with the involvement of numerous physicians, most of whom are not experienced in trauma, may create problems in the medical management of mass casualty incidents.Four hundred patient files admitted in 19 mass casualty events following bombing incidents were reviewed and possible areas which could impact survival were defined.Forty-nine (9.3 %) patients had an Injury Severity Score ≥16. Of 205 patients in whom triage decisions were available, 5 of 25 severely injured patients were undertriaged by the triage officers at the door of the hospital. Following primary evaluation inside the emergency department critical injuries in two patients were missed due to distracting, less serious injuries. Of 68 (16.1 %) patients who were operated, 28 were in need of either immediate, urgent or high-priority operations. Except for neurosurgical cases which needed to be transferred to other hospitals, there was no delay in surgery. One patient underwent negative laparotomy. There were 15 in-hospital deaths, 6 of which were deemed as either anticipated or unanticipated mortality with possibility for improvement.Medical management should be evaluated following MCIs as this may illustrate possible problems which many need to be addressed in contingency planning.

Resumen Introduccion Aunque el tratamiento del traumatismo esplenico ha cambiado en las ultimas decadas, no existen datos de la actitud que los cirujanos espanoles adoptamos frente a este tipo de lesion tan frecuente. El proposito de este estudio es determinar el perfil del traumatismo esplenico en los adultos con traumatismo abdominal severo y el tratamiento que se realiza en nuestro medio. Metodo Estudio de datos de registros de trauma de 6 hospitales espanoles: Hospital Gregorio Maranon, Hospital de Getafe, Hospital Doce de Octubre, Hospital Virgen de la Vega, Hospital de Torrevieja y Corporacio Sanitaria Parc Tauli. Resultados Se analizo a 566 pacientes con lesiones esplenicas (448 hombres y 118 mujeres). El tipo de traumatismo fue fundamentalmente cerrado (94%) y el mecanismo lesional mas frecuente fue el accidente de trafico El ISS medio de la serie fue de 25,2. El tratamiento fue inicialmente quirurgico en el 56,6%, siendo en el 43,4% restante, conservador. De estos, el 6,5% de los pacientes requirio finalmente cirugia y en el 8,8% se realizo angioembolizacion esplenica. De los pacientes intervenidos al inicio, en el 85,3% de los casos se realizo esplenectomia, y cirugia conservadora de bazo en el 14,7%, de los que el 4,6% fracasaron y requirieron nueva intervencion quirurgica con esplenectomia. Conclusion El tratamiento en Espana para el traumatismo esplenico continua siendo en su mayoria quirurgico (fundamentalmente esplenectomia). La angioembolizacion y el tratamiento conservador continuan teniendo escasa presencia.

Background Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level.

Background Trauma injuries are the main cause of death in the world. The aim of this study is to determine how trauma patients are treated in Spain at an organizational level. Material and methods A questionnaire was prepared consisting of 14 questions regarding aspects of the trauma care organization and trauma education. It was posted on the web site of the Spanish College of Surgeons and all members were encouraged to participate. Results One hundred and ninety questionnaires from 110 different hospitals were received. More than two-thirds (67.3%) of the centers had protocols for treating trauma patients, with 81% of them based on ATLS guidelines. Almost three-quarters (72.6%) of the doctors had completed the ATLS course, and 38.9% the DSTC course. There was a specific education program in trauma in 24.5% of the centers, and 35.5% had a Trauma Committee. There was a rehabilitation program in 24.5% of the centers. Conclusion Very few of the participating centers would fulfill the requirements of the American College of Surgeons accreditation for trauma centers. Trauma care in Spain has improved a lot in the recent years, but there is still a lot to do to reach the level of that in the United States of America.

Resumen Introduccion La banda gastrica ajustable es una tecnica afianzada en el mundo en el tratamiento de la obesidad morbida. En Espana, las cifras de pacientes intervenidos de banda gastrica distan mucho de las cifras mundiales, habiendose alegado un alto numero de reintervenciones. Material y metodos En el ano 2001 iniciamos,un programa de tratamiento quirurgico de la obesidad mediante la implantacion de banda gastrica ajustable. Paralelamente, desarrollamos un sistema exhaustivo de seguimiento para evitar complicaciones y mejorar los resultados. Resultados Desde el ano 2001 hasta el 2011 hemos intervenido un total de 132 pacientes, 102 mujeres y 30 hombres, con una edad media de 39 anos y un indice de masa corporal medio de 43. El seguimiento fue superior a 5 anos en 61 pacientes; en el resto, el seguimiento medio fue de 44, 4 meses. La mortalidad y complicaciones graves fue 0. Ocho pacientes requirieron cirugia de revision (6,06%), 3 por complicaciones relacionadas con el reservorio, 4 por deslizamiento y una por erosion. Tres deslizamientos se convirtieron a otra tecnica y otro se resolvio con colocacion de una nueva banda de tipo Lap Band. El porcentaje de sobrepeso perdido medio se mantuvo en los pacientes con un seguimiento superior a los 5 anos en 54,8%. Conclusiones Los resultados de nuestra serie son superponibles a los publicados en la literatura mundial en nuestro medio y demuestran que, reproduciendo el seguimiento realizado, la banda gastrica es un metodo eficaz y seguro para el control del peso en los pacientes con obesidad morbida tambien en Espana.

Resumen Introduccion La banda gastrica ajustable es una tecnica afianzada en el mundo en el tratamiento de la obesidad morbida. En Espana, las cifras de pacientes intervenidos de banda gastrica distan mucho de las cifras mundiales, habiendose alegado un alto numero de reintervenciones. Material y metodos En el ano 2001 iniciamos,un programa de tratamiento quirurgico de la obesidad mediante la implantacion de banda gastrica ajustable. Paralelamente, desarrollamos un sistema exhaustivo de seguimiento para evitar complicaciones y mejorar los resultados. Resultados Desde el ano 2001 hasta el 2011 hemos intervenido un total de 132 pacientes, 102 mujeres y 30 hombres, con una edad media de 39 anos y un indice de masa corporal medio de 43. El seguimiento fue superior a 5 anos en 61 pacientes; en el resto, el seguimiento medio fue de 44, 4 meses. La mortalidad y complicaciones graves fue 0. Ocho pacientes requirieron cirugia de revision (6,06%), 3 por complicaciones relacionadas con el reservorio, 4 por deslizamiento y una por erosion. Tres deslizamientos se convirtieron a otra tecnica y otro se resolvio con colocacion de una nueva banda de tipo Lap Band. El porcentaje de sobrepeso perdido medio se mantuvo en los pacientes con un seguimiento superior a los 5 anos en 54, 8%. Conclusiones Los resultados de nuestra serie son superponibles a los publicados en la literatura mundial en nuestro medio y demuestran que, reproduciendo el seguimiento realizado, la banda gastrica es un metodo eficaz y seguro para el control del peso en los pacientes con obesidad morbida tambien en Espana.

Head injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion.To evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention.Analysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015.Proportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score.Of 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (P .001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (P .001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; P = .83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores.Following an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.

Resumen Introduccion Con el objetivo de demostrar la eficacia de los adhesivos biologicos a base de fibrina en la prevencion de fugas anastomoticas, en enero de 2007 iniciamos un estudio multicentrico, prospectivo, aleatorizado, controlado, simple ciego, sobre la prevencion de fugas anastomoticas en anastomosis del tubo digestivo de alto riesgo mediante la utilizacion de adhesivos biologicos a base de fibrina. Material y metodos En enero de 2007 iniciamos un ensayo clinico multicentrico en el que participan los hospitales Gregorio Maranon, Universitario de San Carlos y Hospital del Sureste, de Madrid sobre la prevencion de defectos de cicatrizacion anastomotica mediante la aplicacion de adhesivos biologicos a base de fibrina en la linea de sutura. Los pacientes reclutados se aleatorizan asignando al paciente en funcion de esta aleatorizacion a uno de los 2 grupos: grupo de estudio en el que se aplica adhesivo en la linea de sutura y grupo control en el que no se aplica. La variable principal del estudio es la presencia o ausencia de fugas. El ensayo ha sido aprobado por los correspondientes Comites de Etica e Investigacion Clinica, por la Agencia Espanola del Medicamento y registrado en www.clinicaltrials.gov (NCT01306851). Ninguno de los autores manifiesta tener conflicto de interes con la empresa Baxter, que comercializa el producto en Espana. Resultados Desde enero de 2007 hasta noviembre de 2010, se ha reclutado a 104 pacientes que han sido asignados tras aleatorizacion, 52 al grupo de estudio y 52 al grupo control. Se han registrado 22 fugas anastomoticas de las cuales 7 en el grupo de estudio (13, 4%) y 15 en el grupo control (28, 8%) con un valor de la P de 0,046. El indice de riesgo de fugas fue de 0,384, es decir, se produce una reduccion del 61% en las fugas de los pacientes a los que se aplica adhesivo biologico a base de fibrina. El grupo de estudio presento 3 reintervenciones (5, 7%) frente a 12 en el grupo control (23%) con un valor de la P de 0, 012. Al analizar la mortalidad, 3 pacientes fallecieron en el grupo de estudio y 4 en el grupo control (5,7 vs 7,7% P = 0, 5). No se ha encontrado ninguna otra asociacion entre ambos grupos relacionada con el tipo de sutura, tiempo quirurgico o antecedentes preoperatorios excepto la utilizacion de drenajes que fue un factor protector de la fuga anastomotica (P = 0,041), aunque la utilizacion o no de drenajes no fue un factor controlado sino a juicio de cada cirujano. Conclusiones Nuestro estudio demuestra de manera significativa a 104 pacientes del inicio del mismo que los adhesivos biologicos a base de fibrina son capaces de prevenir la fuga anastomotica en anastomosis del tubo digestivo de alto riesgo, reduciendo el riesgo de fuga un 61% y el porcentaje de reintervenciones. Se trata del primer ensayo clinico que demuestra de manera significativa estos resultados. Si nuestros resultados se mantienen al cierre del estudio, seran demostrativos de la prevencion de fugas anastomoticas con la aplicacion de estos adhesivos, siendo entonces recomendable su aplicacion en todas las anastomosis del tubo digestivo de alto riesgo.

Resumen Introduccion El trafico de drogas mediante la introduccion de paquetes de sustancias ilicitas en cavidades corporales supone un riesgo de padecer una obstruccion gastrointestinal y/o intoxicacion grave para la persona que las trasporta. Nuestro pais esta considerado como puerta de entrada a Europa para drogas, y algunos hospitales espanoles tienen experiencia en el manejo de este tipo de pacientes. Dos hospitales en Madrid, entre ellos el Hospital General Universitario Gregorio Maranon (HGUGM), reciben estos potenciales pacientes desde el aeropuerto de Barajas. Objetivo Analizar los resultados del tratamiento conservador y de la necesidad de cirugia en los body-packers. Metodos Estudio retrospectivo observacional de pacientes ingresados entre enero de 2000 y diciembre de 2008 con el diagnostico de body-packer. Son ingresados en la Unidad de Custodiados de nuestro centro aquellos con sintomas gastrointestinales, signos de intoxicacion o toxicos positivos. El tratamiento conservador consiste en reposo digestivo y pruebas de imagen hasta la expulsion de los cuerpos. Los pacientes asintomaticos son dados de alta desde el Departamento de Urgencias. Resultados En este periodo hubo 549 pacientes hospitalizados, cuya mediana de edad fue 31 anos. El 81% eran varones. El 40% presentaron toxicos en orina positivos, siendo cocaina el 86% de los casos. De los 549 pacientes con tratamiento inicial conservador, 27 (4,9%) presentaron complicaciones graves (16, obstruccion intestinal y 11, signos de intoxicacion). De estos, 23 requirieron intervencion quirurgica (las 16 obstrucciones y 7 de las intoxicaciones); 2 fueron tratados con exito en la UCI, y otros 2 fallecieron antes de la intervencion (0,4% de los casos). El tratamiento quirurgico mas frecuente fue enterotomia y/o gastrotomia para extraccion de los paquetes. Trece (56%) de los operados presentaron morbilidad asociada (11 infecciones abdominales y 2 infecciones nosocomiales). Conclusiones El tratamiento conservador es seguro en el 95% de los pacientes. Un pequeno porcentaje requeriran tratamiento quirurgico, fundamentalmente por obstruccion gastrointestinal o intoxicacion grave.

Penetrating injuries in the base of the neck are considered to be the most dangerous due to the potential combination of vascular and intrathoracic lesions. We describe an extremely rare case of combined injury of the trachea and innominate artery, which resulted in formation of a traumatic acute tracheoinnominate fistula. Previously, these fistulas have been described as an iatrogenic complication of tracheostomy, presenting with massive peristomal bleed or hemoptysis. This case demonstrates that a combination of lesions to vital anatomical structures in the neck can change their clinical presentation, making them extremely difficult to diagnose.

Resumen Introduccion Las lesiones gastrointestinales y mesentericas (LGIM) son poco frecuentes en el traumatizado, y su diagnostico es, en ocasiones, tardio. Nuestros objetivos han sido determinar la fiabilidad diagnostica inicial de la tomografia computarizada (TC) en nuestro centro, asi como la posible repercusion clinica de la demora diagnostica en estas lesiones. Material y metodo Estudio retrospectivo de los pacientes con LGIM recogidos en nuestro Registro de Trauma Grave entre 1993 y 2006. Resultados De los 1.495 traumatizados registrados, 632 tenian traumatismo abdominal y 105 (16,6%) presentaron LGIM, en un 46% secundarias a un traumatismo cerrado. El ISS y el NISS medios fueron 20 y 25, respectivamente. La mortalidad fue de 9 (8,5%) pacientes, 4 contra pronostico. En 56 (53%) casos se realizo una TC, y se observaron signos de LGIM en solo 37. En otros 43 (41%) pacientes se indico una laparotomia urgente por inestabilidad o signos clinicos de lesion intraabdominal. En 21 (20%) casos la cirugia se demoro mas de 8 h, y la causa mas frecuente fue un falso negativo en la TC. Conclusiones La incidencia total de LGIM ha sido alta en nuestro medio (el 31% en traumatismo abdominal penetrante y el 10,7% en cerrado). Diversos factores como la ausencia inicial de clinica, la baja sensibilidad diagnostica de la TC (un 34% de falsos negativos) y el manejo conservador de las lesiones de organo solido han llevado a diagnostico y tratamiento tardios en 1 de cada 5 pacientes de nuestra serie, sin que ello haya implicado un aumento significativo de la morbilidad infecciosa.

Resumen Introduccion La colitis isquemica (CI) es la forma mas frecuente de enfermedad isquemica digestiva y esta infradiagnosticada. Objetivos Describir los resultados obtenidos en pacientes con CI que necesitaron de intervencion quirurgica en nuestro centro, y evaluar los factores predictores de mortalidad. Metodos Los datos fueron obtenidos de la base de CI del Hospital Gregorio Maranon. Las caracteristicas demograficas, clinicas, los metodos diagnosticos, las tecnicas quirurgicas empleadas y la mortalidad fueron analizados estadisticamente empleando la prueba de la χ2 y la t de Student. Resultados Entre 1991 y 2006, se opero a 101 pacientes con CI. La mayoria de estos tenian antecedentes cardiovasculares y 35 casos fueron diagnosticados durante su ingreso hospitalario por otra causa. Tanto los signos como los sintomas fueron inespecificos en el 40% de los casos. La morbilidad y la mortalidad total fue del 39,6 y el 41,6%, respectivamente. En los casos de CI postoperatoria, la mortalidad se elevo hasta el 68% (p Conclusiones La mortalidad en pacientes afectos de CI que necesitan intervencion quirurgica es alta, especialmente si el diagnostico se hace en el postoperatorio de otra cirugia o si se evidencia necrosis transmural durante la intervencion. Para mejorar estos resultados el diagnostico precoz es la mejor arma, y debe basarse en un alto indice de sospecha.

To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times. Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15. Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic. There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.

Describe the most frequent emergency surgery situations involving the stomach and duodenum (perforated and bleeding gastroduodenal ulcer disease)

This text describes the process of development of the new Spanish Prehospital Advanced Triage Method (META) and explain its main features and contribution to prehospital triage systems in mass casualty incidents. The triage META is based in the Advanced Trauma Life Support (ATLS) protocols, patient’s anatomical injuries and mechanism of injury. It is a triage method with four stages including early identification of patients with severe trauma that would benefit from a rapid evacuation to a surgical facility and introduces a new patient flow by-passing the advanced medical post to improve evacuation. The stages of triage META are: I) Stabilization triage that classifies patients according to severity to set priorities for initial emergency treatment; II) Identifying patients requiring urgent surgical treatment, this is done at the same time than stage I and creates a new flow of patients with high priority for evacuation; III) Implementation of Advanced Trauma Life Support protocols to patients previously classified according to stablished priority; and IV) Evacuation triage, stablishing evacuation priorities in case of lacks of appropriate transport resources. The triage META is to be applied only by prehospital providers with advanced knowledge and training in advanced trauma life support care and has been designed to be implemented as prehospital procedure in mass casualty incidents (MCI).

Categorize different abdominal clinical conditions in relation to the characteristics of the pain and the presence or absence of tenderness

To review the indications for nonoperative management of the more common “surgical” emergencies.

Resumen Introduccion El objetivo de esta revision ha sido conocer la incidencia, lesiones asociadas, tratamiento y resultados obtenidos en el manejo de los pacientes con fracturas graves de pelvis en nuestro centro. Pacientes y metodo Estudio retrospectivo de los pacientes incluidos en nuestro registro de traumatizados graves entre junio de 1993 y enero de 2005. La clasificacion de las fracturas pelvianas se ha realizado con los criterios de Tile. Se comparan y analizan estadisticamente aspectos demograficos y clinicos, incluidos la edad, el sexo, el mecanismo lesivo, tiempo de traslado, la situacion hemodinamica al ingreso y las escalas de gravedad. Se ha definido el estado de shock como una presion arterial sistolica ≤ 90 mmHg durante la revision primaria. Se analizan la mortalidad y los factores de riesgo asociados, con especial enfasis en el grupo de pacientes en shock. Resultados De los 1.274 politraumatizados graves atendidos en el periodo de estudio, 192 (15%) presentaban fractura pelviana. Muy pocas fracturas se han presentado como lesiones aisladas (6,7%), y el porcentaje de fracturas abiertas ha sido del 6%. El 20% de los pacientes presentaba shock al ingreso. El Injury Severity Score (ISS) medio de la serie fue de 28,5 ± 14, y el de los pacientes en shock fue de 38 ± 16. Las lesiones asociadas mas frecuentes fueron las toracicas (70%), seguidas por las abdominales (55%), fracturas de huesos largos (52%) y craneoencefalicas (40%). El 23% de los pacientes presentaba hematoma retroperitoneal. Se realizaron 16 arteriografias y 4 embolizaciones pelvianas. Se colocaron 8 fijadores externos anteriores y ninguno posterior. Se realizaron 5 taponamientos pelvianos y 2 ligaduras de arterias hipogastricas. La mortalidad general fue del 30%, y del 61% en los pacientes en shock al ingreso. El shock a la llegada, una escala de coma de Glasgow ≤ 8, un ISS > 25 y la edad > 55 anos se correlacionaron con la mortalidad. Conclusiones El pronostico de los pacientes en shock y con fracturas de pelvis graves en nuestro medio es sombrio y, con frecuencia, esta condicionado por la gravedad de las lesiones asociadas, la relativa escasa incidencia de estas fracturas y la heterogeneidad de criterios de manejo de los equipos de guardia. La hemorragia masiva incontrolada ha sido la causa principal de muerte.

Though tympanic membrane perforation (TMP) is a marker of barotrauma, relation to severity of injury has been contested based on previous observations that following an explosion many victims with significant injuries do not suffer from TMP while many victims with TMP do not suffer from significant injuries. The objective of this study was to reassess the relationship of TMP to severity of injury and resource demand in patients treated in multiple casualty incidents following terrorist bombings treated in one medical center. Retrospective review. Most of the patients with TMP were mildly injured. Nevertheless, TMP was more prevalent in patients with moderate and severe injuries, 53.3 % compared to 13.6 % in mildly injured patients (p = 0.0009). Patients with TMP suffered from more body areas injured (p