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espanolEl centro de este trabajo refiere a las estrategias de ficcionalizacion que organizan el mundo narrado en Las tierras arrasadas (2015) de Emiliano Monge, en cuyo flujo narrativo se despliega, transtextualmente, la historia de una banda que trafica emigrantes, el discurso testimonial de quienes sobrevivieron a una matanza, mas la insercion de fragmentos de “El infierno” de Dante. En ese contexto, el problema que se aborda en ese espacio ficcional es el sustrato que ordena la novela, en el que si bien atane a la emigracion, la intriga novelesca consiste en el enfrentamiento a muerte de bandas de traficantes humanos. En ese marco, se sostiene la premisa de que en Las tierras arrasadas se pone en discusion un orden social que ha naturalizado la violencia. Se concluye entonces que, a partir de la transtextualidad, se elabora un relato que desborda la novela y compromete el afuera de la palabra literaria, con lo cual Monge se adscribe a un grupo de escritores que proponen nuevas formas de escritura en Latinoamerica del siglo XXI. EnglishThe center of this work refers to the fictionalization strategies that organize the narrated world in Emiliano Monge's Las tierras arrasadas (The destroyed lands) (2015), in whose narrative flow, transtextuality, the story of a gang that traffics migrants, the testimonial discourse of those who survived a massacre, plus the insertion of fragments from Dante's "Hell". In this context, the problem that is addressed in this fictional space is the substratum of the novel orders, in which, although it concerns emigration, the fictional intrigue consists in the confrontation to death of gangs of human traffickers. Within this framework, the premise is maintained that a devastated social order that has naturalized violence is being questioned in Las tierras arrasadas. It is concluded then that, from the transtextuality, a story is elaborated that goes beyond the novel and compromises the outside of the literary word, with which Monge is assigned to a group of writers who propose new forms of writing in Latin America of the 21st century.

Resumen: El tema central de este trabajo focaliza su desarrollo en propuestas teóricas en el ámbito literario, hacia la primera mitad del siglo XX en Hispanoamérica, particularmente el proyecto que formulara el poeta Pablo de Rokha en su texto “La épica social americana”, incorporado en su libro Arenga sobre el arte (1949). La premisa que se postula es que “La épica social americana” constituye una apropiación del discurso totalizador de las vanguardias, proyectada en la imagen heroica del poeta, cuya escritura debiera considerar el contacto entre la cultura ilustrada y la cultural popular. En ese contexto, el objetivo que se busca es recomponer tópicos y líneas de sentido que ordenan el discurso teórico planteado por de Rokha, atendiendo a los énfasis y conexiones con el discurso cultural y literario de sus tesis. Consecuentemente, el centro de la discusión conduce al empleo de conceptos y categorías de orden interdisciplinario, donde es fundamental la idea de apropiación, en vínculo con el contexto en que se produjo su texto.

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%. Resumen El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients. Resumen El manejo definitivo de los pacientes hemodinámicamente estables con heridas cardíacas penetrantes continúa siendo controversial con abordajes invasivos versus manejos conservadores. Estas posiciones contrarias se extienden hasta aquellos casos de pacientes hemodinámicamente inestables donde se ha descrito y considerado la cirugía de control de daños como un procedimiento útil y efectivo. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de heridas cardíacas penetrantes con la creación de un algoritmo práctico que incluye los principios básicos del control de daños. Se recomienda que a todos los pacientes con heridas precordiales penetrantes se les debe realizar un ultrasonido torácico como componente integral de la evaluación inicial. Aquellos que presenten un ultrasonido torácico positivo y se encuentren hemodinámicamente estables se les debe realizar una ventana pericárdica con posterior lavado. Se ha demostrado que el 25% de las ventanas pericárdicas positivas no se benefician ni requieren de posteriores abordajes quirúrgicos invasivos. Antes de este concepto, todos los pacientes con ventana pericárdica positiva terminaban en una exploración abierta del tórax y del pericárdico. Los pacientes hemodinámicamente inestables requieren de una cirugía de control de daños para un adecuado y oportuno control del sangrado. Con este propósito, se propone un algoritmo de manejo quirúrgico que incluye todos estos aspectos esenciales en el abordaje de este grupo de pacientes.

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver. Resumen El hígado es el órgano solido más comúnmente lesionado en casos de trauma abdominal. El manejo del trauma penetrante hepático es un dilema para los cirujanos. Sin embargo, con la introducción del concepto de la cirugía de control de daños y los avances tecnológicos en imagenología y técnicas endovasculares han permitido que el enfoque del tratamiento cambie. La disponibilidad inmediata de la tomografía computarizada permite estadificar el grado de la lesión e incrementar la posibilidad de un manejo conservador en pacientes hemodinámicamente estables con trauma hepático. El trauma hepático severo que se asocia con inestabilidad hemodinámica tiene una alta mortalidad debido a la hemorragia activa. El objetivo de este artículo es proponer un algoritmo de manejo producto de un consenso de expertos acerca del abordaje de los pacientes hemodinámicamente inestables con trauma hepático penetrante. El manejo debe ser por parte de un equipo multidisciplinario que comienza desde la evaluación inicial de los pacientes, la activación temprana de protocolo de transfusión masiva y el control temprano de la hemorragia, siendo estos aspectos esenciales para disminuir la mortalidad. El miedo a lo desconocido es el dilema quirúrgico donde existen pocas opciones y es imperante decisiones rápidas y oportunas; por esta razón, se propone dar una luz de guía sobre lo desconocido respecto al manejo del paciente con trauma hepático severo.

Pancreatic trauma is a rare but potentially lethal injury because often it is associated with other abdominal organ or vascular injuries. Usually, it has a late clinical presentation which in turn complicates the management and overall prognosis. Due to the overall low prevalence of pancreatic injuries, there has been a significant lack of consensus among trauma surgeons worldwide on how to appropriately and efficiently diagnose and manage them. The accurate diagnosis of these injuries is difficult due to its anatomical location and the fact that signs of pancreatic damage are usually of delayed presentation. The current surgical trend has been moving towards organ preservation in order to avoid complications secondary to exocrine and endocrine function loss and/or potential implicit post-operative complications including leaks and fistulas. The aim of this paper is to propose a management algorithm of patients with pancreatic injuries via an expert consensus. Most pancreatic injuries can be managed with a combination of hemostatic maneuvers, pancreatic packing, parenchymal wound suturing and closed surgical drainage. Distal pancreatectomies with the inevitable loss of significant amounts of healthy pancreatic tissue must be avoided. General principles of damage control surgery must be applied when necessary followed by definitive surgical management when and only when appropriate physiological stabilization has been achieved. It is our experience that viable un-injured pancreatic tissue should be left alone when possible in all types of pancreatic injuries accompanied by adequate closed surgical drainage with the aim of preserving primary organ function and decreasing short and long term morbidity. Resumen El trauma pancreático es un tipo de trauma poco común potencialmente fatal que está asociado con lesiones de órganos abdominales o vasculares. Usualmente, los signos clínicos son tardíos aumentado el riesgo de complicaciones respecto al manejo y al pronóstico general. Debido a la baja prevalencia de la lesión del trauma, no existe consenso entre los cirujanos alrededor del mundo sobre cómo se debe diagnosticar y tratar adecuadamente este desafío quirúrgico. La precisión en el diagnóstico es difícil por la localización anatómica y las manifestaciones clínicas tardías. El abordaje quirúrgico ha ido cambiando de dirección hacia la preservación del órgano para evitar complicaciones secundarias asociada a la perdida de la función exocrina y endocrina, o de potenciales complicaciones postquirúrgicas incluyendo las dehiscencias y fistulas. El objetivo de este artículo es proponer un algoritmo de manejo del trauma pancreático a través de un consenso de expertos. Las lesiones del páncreas pueden ser manejadas con una combinación de maniobras hemostáticas, empaquetamiento pancreático, sutura de la herida y drenaje quirúrgico cerrado. La pancreatectomía distal con la perdida de tejido vital pancreático debe ser evitadas. Los principios generales de la cirugía de control de daños deben ser aplicados cuando sea necesario para un manejo quirúrgico definitivo cuando y solo cuando la estabilización fisiológica haya sido lograda. En nuestra experiencia, el tejido pancreático sano debe preservarse cuando el trauma se asocia de un manejo mediante un drenaje quirúrgico cerrado con el objetivo de preservar la función primaria del órgano y disminuir a corto y largo tiempo las morbilidades.

Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm "The Fourth Pillar": Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.La resucitación en control de daños busca combatir la descompensación metabólica del paciente severamente traumatizado mediante tres ejes: la hipotensión permisiva, la resucitación hemostática y la cirugía de control de daños. El objetivo de este artículo es hacer una revisión de la historia de la resucitación en control de daños y la cirugía de control de daños proponiendo un nuevo paradigma basado en los recientes avances de la tecnología endovascular. Un puente ha sido creado entre el manejo prehospitalario y el control del sangrado, descrito antes de la etapa I de la cirugía de control de daños, que es la inclusión y colocación de un REBOA. Esta es una herramienta adicional en el control de la hemorragia y de soporte en la resucitación hemodinámica de los pacientes con trauma severo de tipo cerrado y/o penetrante. Por lo que se propone un nuevo paradigma “El cuarto pilar”: Hipotensión permisiva, resucitación hemostática, cirugía de control de daños y REBOA.

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.En pacientes con trauma de abdomen que requieren laparotomía, hasta una cuarta o tercera parte, habrán sufrido una lesión vascular. Las estructuras venosas principalmente lesionadas son la vena cava y las iliacas, y de vasos arteriales, son las iliacas y la aorta. El abordaje de este tipo de heridas vasculares se puede ser difícil en el contexto de un paciente hemodinámicamente inestable ya que requiera medidas rápidas que permita controlar la exanguinación del paciente. El objetivo de este manuscrito es presentar el abordaje del trauma vascular abdominal de acuerdo con la filosofía de cirugía de control de daños. La primera prioridad en una laparotomía por trauma es el control de la hemorragia. Las hemorragias de origen intraperitoneal se controlan con compresión, pinzamiento o empaquetamiento, y las retroperitoneales con compresión selectiva. Posterior al control transitorio de la hemorragia, se debe identificar la estructura vascular comprometida, de acuerdo con la localización de los hematomas. El manejo de las lesiones debe orientarse a la finalización expedita de la laparotomía, enfocado en el control de la hemorragia y contaminación, con aplazamiento del manejo definitivo. Lo pertinente al tratamiento de las lesiones vasculares incluyen la ligadura, derivación transitoria y el empaquetamiento de vasos seleccionados de baja presión y de superficies sangrantes. Posteriormente se debe realizar el cierre no convencional de la cavidad abdominal, preferiblemente con sistemas de presión negativa, para consecutivamente reoperar una vez corregidas las alteraciones hemodinámicas y la coagulopatía para realizar el manejo definitivo.

In cardiac trauma there are two basic scenarios: 1. The patient is stable. In this case the best access is median sternotomy, because: It is less painful for the patient The exposure for the heart and the great vessels is optimal The disadvantage is that this approach provides limited access to other potentially injured structures, such as the lung, subclavian vessels, aorta, and intercostal vessels. 2. The patient is unstable. In this case the anterolateral thoracotomy offers several advantages: It is faster It can be made with basic instruments It allows access to several structures besides the heart

Los artículos que dan forma al libro Discurso crítico e invención literaria. Huellas y trazos de la cultura entre dos siglos, han sido publicados anteriormente en revistas especializadas. En su origen, algunos constituyeron trabajos académicos, que luego fueron expuestos en congresos internacionales; otros provienen de líneas conceptuales desarrolladas en mi Tesis doctoral. Por último, se agrega un conjunto de estudios elaborados en el contexto de un proyecto independiente de investigación, e...

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively. Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management. Resumen Las técnicas de control de daños aplicadas al manejo de lesiones torácicas han evolucionado en los últimos 15 años. A pesar de que el número de publicaciones es limitado, la información es suficiente para desvirtuar algunos temores y establecer los principios de manejo. La severidad del compromiso anatómico justifica el procedimiento de control de daños solamente en algunos casos. En la mayoría, la magnitud del deterioro fisiológico y la presencia de otras fuentes de sangrado dentro del tórax o en otros compartimientos corporales constituyen la indicación del procedimiento abreviado. La clasificación de la lesión pulmonar como periférica, transfixiante y central o múltiple, proporciona una pauta para el control transitorio del sangrado y para el manejo definitivo de la lesión: neumorrafía, resección en cuña, tractotomía o resecciones anatómicas, respectivamente. La identificación de ciertos patrones como la necesidad de toracotomía de reanimación o de oclusión aórtica, la existencia de un hemotórax masivo, de una lesión pulmonar central, una lesión traqueobronquial o una lesión vascular mayor, así como el reconocimiento de hipotermia, acidosis o coagulopatía, constituyen la indicación de una toracotomía de control de daños. En estos casos, el cirujano concluye de manera abreviada los procedimientos con empaquetamiento de las superficies sangrantes, el manejo primario con empaquetamiento de algunas lesiones pulmonares periféricas o transfixiante seleccionadas y el aplazamiento de la resección pulmonar, pinzando el hilio de la manera más selectiva posible. La abreviación del cierre de la toracotomía se logra con la sutura de la piel sobre el empaquetamiento de la herida, o mediante la instalación de un sistema de presión negativa. El manejo del paciente en cuidados intensivos permitirá identificar aquellos que requieren reintervención urgente y corregir la alteración fisiológica de los restantes para su reoperación programada y manejo definitivo.

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma which are commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and consequential increase in the rates of mortality. The aim of this article is to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery which sticks to the philosophy of “Less is Better”. Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability and/or significant associated injuries then the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

ResumenEl tema central de este artí­culo refiere al problema de la crí­tica, enmarcándolo en la tradición de los estudios de discurso e interpretación cultural. En ese contexto, sus ejes de desarrollo tienen como propósito abordar, en términos teóricos, el ví­nculo de ensayo y crí­tica con los aspectos conceptuales que conducen hacia su dimensión discursiva y textual. En un segundo momento, se propone referir a una panorámica de proyectos teóricos y crí­ticos latinoamericanos de la segunda mitad del siglo XX, cuyo efecto devino en "categorí­as fundantes".Palabras clave: proyecto teórico - narrativas culturales - categorí­as fundantes AbstractThe main subject of this article refers to the criticism problem, framed it in the tradition of discourse studies and cultural interpretation. In this context, its development priorities are intended to address, in theoretical terms,the link between essay and criticism, with the conceptual aspects that lead them to the discursive and textual dimension. In a second level, it is proposed to refer to an overview of Latinoamerican critics projects of the second half of the twentieth century, where its effects became into "founding categories".Key words: theorical project - cultural narratives -founding categories*

Intestinal obstruction is an interruption of the normal enteric flow in either small or large bowel. An obstruction before the ileocecal valve is considered a proximal bowel obstruction and after the valve is called a distal bowel obstruction. Both can have a mechanical or functional etiology. The management may differ depending on the cause of the bowel obstruction.

BACKGROUND: The traditional management of complex penetrating duodenal trauma (PDT) has been the use of elaborate temporizing andcomplexproceduressuchasthepyloricexclusionandduodenaldiverticulization.Wesoughttodeterminewhetherasimplifiedsurgical approach to the management of complex PDT injuries improves clinical outcome.METHODS: A retrospective review of all consecutive PDT from 2003 to 2012 was conducted. Patients were divided into three groupsaccording to a simplified surgical algorithm devised following the local experience at a regional Level I trauma center.Postoperative duodenal leaks were drained externally either via traditional anterior drainage or via posterior ‘‘retroperitoneallaparostomy’’ as an alternate option.RESULTS: There were 44 consecutive patients with PDT, and 41 of them (93.2%) were from gunshot wounds. Seven patients wereexcluded owing to early intraoperative death secondary to associated devastating traumatic injuries. Of the remaining36patients,7(19.4%)were managedwith single-stage primary duodenalrepairwithdefinitiveabdominalwall fascialclosure(PDR + NoDC group). Damage-control laparotomy was performed in 29 patients, (80.5%) in which primary repair wasperformed in 15 (51.7%) (PDR + DC group), and the duodenum was over sewn and left in discontinuity in 14 (48.3%).Duodenal reconstruction was performed after primary repair in 2 of 15 cases and after left in discontinuity in 13 of 14 cases(DR+ DCgroup).The mostcommoncomplicationwas thedevelopmentofa duodenalfistulain 12(33%)of36cases.Theseleaks were managed by traditional anterior drainage in 9 (75%) of 12 cases and posterior drainage by retroperitoneallaparostomy in 3 (25%) of 12 cases. The duodenal fistula closed spontaneously in 7 (58.3%) of 12 cases. The duodenum-related mortality rate was 2.8%, and the overall mortality rate was 11.1%.CONCLUSION: An application of basic damage-control techniques for PDT leads to improved survival and an acceptable incidence ofcomplications. (J Trauma Acute Care Surg. 2014;76: 1177Y1183. Copyright * 2014 by Lippincott Williams & Wilkins)LEVEL OF EVIDENCE: Therapeutic study, level IV.KEY WORDS: Duodenal injuries; penetrating injuries; pyloric exclusion; retroperitoneal laparostomy; damage-control laparotomy.

Objective To send an American fellow surgeon to a Panamerican country and quantify operative skills acquisition. Materials and methods A second year surgical critical care fellow from a Level One Urban Trauma Center was sent to Cali, Colombia from April 1 to 21, 2013. The operative experience was evaluated. Total cases, first time cases, and first time procedures, defined as technical portions within trauma cases, were recorded. Results In 20 operative days, 172 total cases were performed in the following categories: burn 112, trauma 19, emergent general 16, elective general 14, plastics 8, and laparoscopic bariatric 3. First exposure operations included 46/112 burn cases, 8/8 trauma/burn reconstructive cases, 1/16 emergent general cases, 11/14 elective general cases, and 3/3 laparoscopic bariatric cases. Of the 19 total trauma operations (not including 2 amputations), 3 left anterolateral thoracotomies, 2 clamshell thoracotomies, 1 diagnostic laparoscopy, 1 open pericardial window, 10 exploratory laparotomies and 2 relaparotomies were performed. The 19 trauma operations consisted of 26 (not including the 2 amputations) procedures. Twenty-three percent were first time performed trauma procedures (6/26, not including amputations). Nearly 9 (8.6) operations were performed per day. In five 12-hour shifts of trauma call, 19 operations were performed within 60 hours. One trauma operative case was performed for every 3.15 hours worked. Conclusion In the current era of American trauma training in which penetrating trauma and total number of operative cases is concentrated to specific centers in the United States, additional methods in education and experience should be sought for the American trauma fellow. This is the first reported international trauma fellow rotation in Cali, Colombia, with an operative experience very different than standard and current opportunities. Our experience serves as a potential template for future endeavors in surgical education. How to cite this article Peck GL, Paula F, Joseph H, Ferrada R, Christopher D, Ordonez C, Aboutanos M, Gracias V. Can We augment the US Trauma Fellow's Operative Training? The PTS Fellowship: A US Surgical Critical Care Fellow's Experience in Colombia. Panam J Trauma Crit Care Emerg Surg 2014;3(1):1-7.

El tema central de este trabajo aborda el dialogismo entre la historia legitimada y la historia ficcionada en la novela Mapocho de Nona Fernández, quien muestra en su texto el cruce de fronteras discursivas, en la cual convergen el pulso vital de la historia y la ficción literaria. A partir de un relato construido desde la recursividad de la historia, se plantea la opción de un contradiscurso, en que las utopí­as se proyectan desde la sospecha del pasado, además de invitar al lector a (des)articular el hilvanado entre pretérito y presente, llenando lasfisuras de la historiografí­a.

In the future, trauma research and care will have to become better, faster, and less expensive. Surgeons in the next millennium must be able to diagnose wounds, initiate correct procedures, and anticipate complications more accurately than before. Violent crime will not abate, nor will the proliferation of more powerful arms; these trends translate into graver traumatic wounds, giving the operating team less time to stabilize patients. Time management and team coordination are becoming key elements for patient survival, especially for patients with potentially fatal wounds, such as those to the heart. The authors have reduced the time from arrival to surgery to a few minutes. The keys to this feat are readiness, team coordination, and high morale. Financial resources will continue to be limited and allocated on a need-first basis. In the future, trauma centers will compete for dwindling funds. Technology is and always will be just a tool, whereas qualified trauma surgeons are irreplaceable, much more so than in any other surgical specialty. Observation, diagnosis, and surgery are, of course, greatly facilitated by ever-evolving technology, but since the time of Hippocrates, split-second decisions can ultimately be made only by the caregiver in the white smock. Trauma surgeons in the next millennium will have to exercise judgment based on knowledge, surgical skills, and contact with patients. To err is human, but in surgery, errors often cause death, and no machine will ever relieve surgeons of that burden.

BACKGROUND: The objective of this study was to describe a comprehensive five-step surgical management approach for patients with penetrating liver trauma based on our collective institutional experience. METHODS: A prospective consecutive study of all penetrating liver traumas from January 2003 to December 2011 at a regional Level I trauma center in Cali, Colombia, was conducted. RESULTS: A total of 538 patients with penetrating thoracoabdominal trauma were operated on at our institution. Of these, 146 had penetrating liver injuries that satisfied the inclusion criteria for surgical intervention to manage their hepatic and/or associated injuries. Eighty-eight patients (60%) had an American Association for the Surgery of TraumaYOrgan Injury Scale (AAST-OIS) of Grade III (54 patients, 37%), Grade IV (24 patients, 16%), and Grade V (10 patients, 7%). This group of patients required advanced ‘‘complex’’ techniques of hemostasis such as the Pringle maneuver (PM), perihepatic liver packing (PHLP), and/or hepatotomy with selective vessel ligation (SVL). The focus of our study was this subgroup of patients, which we further divided into two as follows: those who required only PM + PHLP (55 patients, 63%) to obtain control of their liver hemorrhage and those who required PM + PHLP + SVL (33 patients, 37%). Of the patients who required PM + PHLP + SVL, 10 (27%) required ligation of major intrahepatic branches, which included suprahepatic veins (n = 4), portal vein (n = 4), retrohepatic vena cava (n = 1), and hepatic artery (n = 1). The remaining 23 patients (73%) required direct vessel ligation of smaller intraparenchymal vessels. The overall mortality was 15.9% (14 of 88), with 71.4% (10 of 14) related to coagulopathy. Mortality rates for Grade III was 3.7% (2 of 54), for Grade IV was 20.8% (5 of 24), and for Grade V was 70% (7 of 10). The mortality in the PM + PHLP + SVL group was higher compared with the PM + PHLP group (12 [36.4%] vs. 2 [3.6%], p =0 .001]. CONCLUSION: For those patients who fail to respond to PM + PHLP and/or those who have AAST-OIS penetrating liver injuries, Grades IV and V would benefit from immediate intraparenchymal exploration and SVL. (J Trauma Acute Care Surg. 2013;75: 207Y211. Copyright * 2013 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level V.

Pelvic radiography in blunt trauma patients is routinely used in most trauma centers. The purpose of this review was to evaluate the ability of physical examination alone to detect pelvic fractures. Among patients with blunt trauma admitted to the University Hospital del Valle in Cali, Colombia, over a 3-month period, 608 adult patients, with hemodynamic stability, without spinal involvement, and with a Glasgow Coma Scale score greater than 10 were evaluated. All patients had physical examination, pelvic x-ray and adequate follow-up. Fifty-nine (9.7%) patients had pelvic fractures, with 57 of these fractures detected by physical findings. The remaining two patients had stable fractures that required no treatment. After careful analysis, we conclude that a negative physical examination following blunt trauma has a negative predictive value of 99% probability in excluding pelvic fracture, provided that the patient is not a child, is not in coma, is hemodynamically stable without evidence of blood loss, and has no spinal cord injury. A selective use of pelvic x-ray in patients with blunt trauma is a cost-effective policy.

The study reported here evaluated the efficacy of antibiotics administered in two periods: preoperative only and additional doses postoperatively. There was no difference in developing surgical sepsis between the groups when they included antibiotics preoperatively and the severity of the trauma was minor (Abdominal Trauma Index [ATI] value25). Additionally, the result was the same when one of the injured organs was the colon, in contrast with past studies. One interesting point is related to the association of a Revised Trauma Index value20 with a colon wound: in the present study, this combination had a deleterious effect on the patients, always resulting in abdominal sepsis. Emphasis is placed on the economic benefits of the abolition of postoperative antibiotic use in patients with ATI score less than 25.

Popliteal arterial injuries carry a high risk of amputation. The currently available literature from both civilian and military experiences is characterized by a wide variation of recommendations for surgical management. We questioned how these recommendations have been applied in our practice. Therefore, we aimed to identify predictors of amputation after popliteal arterial injury.We conducted an observational study of 175 patients with popliteal arterial injuries who underwent surgical treatment from 1992 to 2006 at a level I trauma center in Cali, Colombia. Information on demographic characteristics, clinical information, and surgical management was collected from clinical records. The outcome measure was amputation within 30 days following the first surgical intervention.The amputation rate was 17.1%. A multivariable logistic regression model indicates that blunt mechanism (odds ratio [OR] 4.79, 95% confidence interval [CI] 1.49-15.42), signs of ischemia (OR 5.29, 95% CI 1.48-18.91), ligation of the popliteal vein of the compromised limb during surgical exploration (OR 3.83, 95% CI 1.20-12.18), and the development of arterial thrombosis (OR 56.51, 95% CI 12.36-258) were found to be independent predictors of amputation. Fractures, popliteal venous injuries, prolonged time between injury and surgery, fasciotomies, and graft arterial repair were not statistically significant predictors of amputation.Emphasis on the early assessment and prompt identification of signs of ischemia after popliteal arterial injury continue to be the most important factor for reducing the risk of amputation, especially in blunt trauma. Vascular trauma teams must emphasize the need for the specialized management of popliteal veins. Clinical research is needed in order to identify means of decreasing arterial thrombosis after popliteal repair.