trauma de esófago y estómago
TRANSCRIPT
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Trauma de esófago y estómago
VARGAS FLORES EDGAR R2CG
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TRAUMA DE ESÓFAGO
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INCIDENCIA Y MECANISMO
• <1% de lesiones traumáticas• >80% son por lesiones penetrantes de cuello (0.5 a 7%)• 0.7% lesión intratorácica• HPAF: 43 – 95%• Punzocortante: 7 – 57%• Contusión <0.1%
Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
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DIAGNÓSTICO
• Mecanismo• Síntomas• Disfonía• Enfisema• Desviación traqueal
• No detectado• Infección
•Mediastinitis
Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
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DIAGNÓSTICO
• Trago hidrosoluble• Falla hasta en 15%
• Esofagoscopía + estudio contrastado
Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
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MANEJO
• Control de fuga• Desbridamiento• Drenaje• Apoyo nutricional
Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
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ABORDAJE QUIRÚRGICO
• Cervical• Incisión en collar
• 2/3 superiores• Toracotomía posterolateral derecha
• 1/3 inferior• Toracotomía posterolateral izquierda
Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
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REPARACIÓN
• Cierre primario (24 horas)• Parches
• Pericardio• Grasa pericárdica• Diafragmático• Dorsal ancho o romboides.
• Esofagostomía• Drenaje
• Diagnóstico tardío• Sonda en T
Feliciano DV, Mattox KL et al. Trauma. 6th edition. McGraw Hill; 2008
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TRAUMA DE ESTÓMAGO
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CAMERARUIS:
1822 quien reparó una herida por floreteen el cuadrante superior izquierdo e hizohistoria por que la herida se convirtió enuna fístula gástrica cutánea con la cuallogró vivir hasta los 82 años.
Loria FL. Historical aspects of penetrating wounds of the abdomen. Inst Abstr Surg 87:521, 1948.
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Mikulicz realiza la primeralaparotomía exploradora en1885 por ruptura espontáneade estómago.
La primera operación gástrica por arma de fuego se atribuyea Theodore Kocher.
Intervención al Presidente William McKinley quien recibe unimpacto de bala, se le somete a cirugía pero fallece a losocho días.
Loria FL. Historical aspects of penetrating wounds of the abdomen. Inst Abstr Surg 87:521, 1948.
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Lesion gastrica de trauma penetrante 7 a 20 %
Lesion gastrica de trauma cerrado 0.4 a 1.7 %
Astudillo R et al. Trauma, Diez años de experiencia, Hospital Vicente Corral Moscoso.Rev. Ecuatoriana de T rauma. Vol. 1 N 1. 2006
INCIDENCIA Y MECANISMO
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MORTALIDAD:
TRAUMA CERRADO:
0% - 66 % ( Media 30% )
TRAUMA ABIERTO:
14% - 20%
Shinkawa H, Yasuhara H, Nika S, et al: Characteristic features of abdominal organ injuries associated with gastric rupture in blunt abdominal trauma. Am J Surg 187:394–397, 2004.
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MECANISMOS DE LESION
CERRADO- DESACELERACION
- DESCOMPRESION
- CONTUSION
ABIERTO
Fakhry S, Watts D, Daley B, et al.: Current diagnostic approaches lack sensitivity in the diagnosis of perforating blunt small bowelinjury (SBI): Findings from a large multi-institutional trial. J Trauma 51:1232, (abstract) 2001.
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CLINICO:
- HISTORIAL DE TRAUMATISMO
SINTOMAS:
- DOLOR ABDOMINAL
-DIFICULTAD RESPIRATORIA
- HIPO - ANOREXIA
DIAGNÓSTICO
Fakhry S, Watts D, Daley B, et al.: Current diagnostic approaches lack sensitivity in the diagnosis of perforating blunt small bowelinjury (SBI): Findings from a large multi-institutional trial. J Trauma 51:1232, (abstract) 2001.
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SIGNOS:
- HEMATEMESIS
- CONTENIDO HEMATICO SNG
- RIGIDEZ ABDOMINAL
- TAQUICARDIA, HIPOTENSION
- IDENTIFICACION DE LESIONES
- AREA RELACIONADA- ORIFICIOS DE ENTRADA-SALIDA- OBJETOS PUNZO-CORTANTES- HEMATOMAS- LACERACIONES- EQUIMOSIS- EVISCERACION
Fakhry S, Watts D, Daley B, et al.: Current diagnostic approaches lack sensitivity in the diagnosis of perforating blunt small bowelinjury (SBI): Findings from a large multi-institutional trial. J Trauma 51:1232, (abstract) 2001.
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LABORATORIO:
- LEUCOCITOSIS
- AMILASA
- ACIDOSIS METABOLICA
Fakhry S, Watts D, Daley B, et al.: Current diagnostic approaches lack sensitivity in the diagnosis of perforating blunt small bowelinjury (SBI): Findings from a large multi-institutional trial. J Trauma 51:1232, (abstract) 2001.
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Focused Abdominal Sonography for Trauma (FAST)
“This is not as sensitive as DPL or CT in detectingstomach or small bowel injuriesSensitivity 83.7% and specificity 99.7% fordetecting hemoperitoneum”
Fakhry S, Watts D, Daley B, et al.: Current diagnostic approaches lack sensitivity in the diagnosis of perforating blunt small bowelinjury (SBI): Findings from a large multi-institutional trial. J Trauma 51:1232, (abstract) 2001.
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LAVADO PERITONEAL:
-SANGRE FRESCA o-RECUENTO DE HEMATIES >500/mm3
ES UN INDICADOR POSITIVO NO ESPECIFICO DE PERFORACION INTESTINAL.
- AMILASA >20 IU/L SENSBILIDAD 54%, ESPECIFICIDAD 48%
- FA >10 IU ESPECIFICIDAD 99.8% SENSIBILIDAD 94.7
-WBC ≥RBC/150 SENSIBILIDAD 96.6% ESPECIFICIDAD 99.4% despues de 3 horas de la lesion
Fang JF, Chen RJ, Lin BC: Cell count ratio: New criterion of diagnostic peritoneal lavage for detection of holloworgan perforation. J Trauma 45: 540, 1998.
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Fakhry S, Watts D, Daley B, et al.: Current diagnostic approaches lack sensitivity in the diagnosis of perforating bluntsmall bowel injury (SBI): Findings from a large multi-institutional trial. J Trauma 51:1232, (abstract) 2001.
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TOMOGRAFIA COMPUTARIZADA
Mas común en la evaluacion del abdomen en pacientehemodinamicamente estables
-Traumas cerrados- Ocasionalmente en traumas abiertos
Econtrando: fluido intraperitoneal, pneuoperitoneo, inflamacion de grasaperitoneal, hematomas mesentericos, extravasacion del contraste
Sensibilidad 88.3% especificidad 99.4%
Fakhry S, Watts D, Daley B, et al.: Current diagnostic approaches lack sensitivity in the diagnosis of perforating bluntsmall bowel injury (SBI): Findings from a large multi-institutional trial. J Trauma 51:1232, (abstract) 2001.
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Nicholas JM, Parker Rix E, Esley KA, et al: Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma 55:1095–1110, 2003.
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Watts DD, Fakry SM: EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma 54:289–294, 2003.
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-EVACUACION DEL HEMATOMA
- HEMOSTASIA
- SUTURA CONTINUA 1 o 2 PLANOS
-SEDA, PROLENE 3-0 o 4-0 EXTERIOR- ABSORBIBLE 3-0 o 4-0 INTERIOR
Watts DD, Fakry SM: EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma 54:289–294, 2003.
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- MISMA TECNICA POR 2 PLANOS
-USAR ENGRAPADORA GIA
- TENER CUIDADO Y PREVENIR ESTENOSIS (GE y PILORO)
Watts DD, Fakry SM: EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma 54:289–294, 2003.
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LESIONES EXTENSAS:
- GASTRECTOMIA PARCIAL (DISTAL – PROXIMAL) CON GASTRODUODENO ANASTOMOSIS
- GASTRECTOMIA DISTAL CON GASTROYEYUNO ANASTOMOSIS
- GASTRECTOMIA PROXIMAL Y ESOFAGOGASTRECTOMIA Y PILOROPLASTIA.
Watts DD, Fakry SM: EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma 54:289–294, 2003.
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Gracias