Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury.

BACKGROUND: Emergency lung resection following penetrating chest trauma has been associated with mortality rates as high as 55-100%. Pulmonary tractotomy is advocated as a rapid alternative method of dealing with deep lobar injuries. We reviewed our experience with resection and tractotomy to determine whether method of management affects mortality or if patient presentation is more critical in determining outcome. METHODS: A retrospective review of all patients with chest injury seen at an urban Level I trauma center from 2/89-1/99 was performed. All patients undergoing parenchymal surgery were included. Records were abstracted for grade of injury, type of resection, presenting systolic blood pressure (SBP), temperature, Injury Severity Score (ISS), operative time, and estimated blood loss (EBL). Mortality and thoracic complications were compared between groups. RESULTS: Two hundred forty-six of 2736 patients with penetrating chest trauma underwent thoracotomy, with 70 (28%) requiring some form of lung resection. There were 11 (15.7%) deaths. Patients who died had lower SBP (53 +/- 32 mm Hg vs 77 +/- 28 mm Hg), lower temperature (32.5 degrees +/- 1.3 degrees C vs 34.3 degrees +/- 1.2 degrees C), higher ISS (33 +/- 13 vs 23 +/- 9), and greater EBL (9.8 +/- 4.3 liters vs 2.8 +/- 2.1 liters) compared with survivors (p < 0.05 for all). Mortality was also increased in the presence of cardiac injury (33% with vs 12% without) and the need for laparotomy (26% with vs 9% without) (p < 0.05 for all). Tractotomy was associated with an increased incidence of chest complications (67% vs 24%, p = 0.05) compared with lobectomy with no difference in presenting physiology, operative time, or mortality. CONCLUSION: Lung resection for penetrating injuries can be done safely with morbidity and mortality rates lower than previously reported. Patient outcome is related to severity of injury rather than type of resection. Tractotomy is associated with a higher incidence of infectious complications and is not associated with shortened operative times or survival.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma.

OBJECTIVE: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS: This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis. RESULTS: The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION: Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Characterization of the binding sites for plasminogen and tissue-type plasminogen activator in cytokeratin 8 and cytokeratin 18.

Cytokeratin 8 (CK8) is an intermediate filament protein that penetrates to the external surfaces of breast cancer cells and is released from cells in the form of soluble heteropolymers. CK8 binds plasminogen and tissue-type plasminogen activator (t-PA) and accelerates plasminogen activation on cancer cell surfaces. The plasminogen-binding site is located at the C-terminus of CK8. In this study, we prepared GST-fusion proteins which contained either 174 amino acids from the C-terminus of CK8 (CK8f) or 134 amino acids from the C-terminus of CK18 (CK18f). A third GST-CK fusion protein was identical to CK8fexcept that the C-terminal lysine was mutated to glutamine (CK8fK483Q). CK8f bound plasminogen; the K(D) was 0.5 microM. Binding was completely inhibited by epsilonACA. CK8fK483Q also bound plasminogen, albeit with decreased affinity (K(D) approximately 1.5 microM). CK18f did not bind plasminogen at all. All three fusion proteins bound t-PA equivalently, providing the first evidence that CK18 may function as a t-PA receptor, t-PA and plasminogen cross-competed for binding to CK8f. Thus, t-PA and plasminogen cannot bind to the same CK8f monomer simultaneously. Nevertheless, CK8f still promoted plasminogen activation, probably reflecting the fact that CK8f was purified in dimeric or tetrameric form. These studies demonstrate that CK8 may promote plasminogen activation by t-PA only when present in an oligomerized state. CK18 may participate in the oligomer, together with CK8, based on its ability to bind t-PA.

A comparison of rigid -v- video thoracoscopy in the management of chest trauma.

Between December 1, 1994 and April 1,1998, 44 thoracoscopic procedures were performed in 42 patients following chest injuries. Indications included exploration in 15, retained haemothorax in 10, continued bleeding after chest tube placement in 3, air leak in 5 and empyema in 11. Video thoracoscopy was used in 24 cases and rigid thoracoscopy in 20, including 14 patients in whom video thoracoscopy was contraindicated. There was no difference in the operative times, length of stay or incidence of complications. Two formal and 3 "mini" thoracotomies were used in the video thoracoscopy group. Three "mini" thoracotomies were required in the rigid thoracoscopy group. Rigid thoracoscopy is an effective tool that, in selected cases, increases the utility of thoracoscopy in the management of chest trauma and its complications.

Cytokeratin 8 released by breast carcinoma cells in vitro binds plasminogen and tissue-type plasminogen activator and promotes plasminogen activation.

Cell-surface activation of plasminogen may be important in diseases that involve cellular migration, including atherosclerosis and tumour invasion/metastasis. Cytokeratin 8 (CK 8) has been identified as a plasminogen-binding protein expressed on the external surfaces of hepatocytes and breast carcinoma cells [Hembrough, Vasudevan, Allietta, Glass and Gonias (1995) J. Cell Sci. 108, 1071-1082]. In this investigation, we demonstrate that a soluble form of CK 8 is released into the culture medium of breast cancer cell lines. The released CK 8 is in the form of variably sized polymers that bind plasminogen and promote the activation of [Glu1]plasminogen and [Lys78]plasminogen by single-chain tissue-type plasminogen activator (sct-PA). To assess the mechanism by which CK 8 promotes plasminogen activation, CK 8 was purified from rat hepatocytes and immobilized in microtitre plates. Immobilized CK 8 bound 125I-plasminogen and 125I-sct-PA in a specific and saturable manner. The KDs were 160 +/- 40 nM and 250 +/- 48 nM, respectively. Activation of plasminogen bound to immobilized CK 8 was accelerated compared with plasminogen in solution, as determined using a coupled-substrate fluorescence assay and SDS/PAGE. The ability of CK 8 to promote plasminogen activation may be important in the pericellular spaces surrounding breast cancer cells and at the cell surface.