[Observational studies to evaluate robotic-assisted lung cancer surgery?] / Les études observationnelles pour évaluer la chirurgie robotique pour le cancer bronchique ?

BACKGROUND: The aim of this work is to assess the quality of observational studies and to make direct and indirect comparisons of robotic surgery with other approaches. METHOD: We searched various databases between 2014 and 2024 for observational studies comparing robotic-assisted surgery to thoracoscopy or thoracotomy. RESULTS: Eighteen studies were included in the meta-analysis. Risk of confounding bias was present in 90% of studies, while risk of classification bias appeared in 80%. Robotic-assisted surgery reduced the risk of conversion to thoracotomy compared with thoracoscopy with an odds ratio of 0.21 (95% confidence interval: 0.06-0.65), with high heterogeneity between studies (I2=80%). Robotic-assisted surgery did not significantly reduce postoperative complications or 30-day mortality compared with thoracotomy or thoracoscopy. For 5-year overall survival, comparisons of robotic-assisted surgery to thoracoscopy or thoracotomy were non-significant with I2 of 55%. CONCLUSION: This work demonstrates the need for a randomized controlled trial to validate robotic surgery for the treatment of bronchial cancer.

Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries.

INTRODUCTION: There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS. METHODS: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (pediatric [<18 y], adults [18-64 y], and older adults [≥65 y]). Our primary outcome measures included 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. RESULTS: We identified 14,192 thoracotomies, out of which 213 underwent TDCS (pediatric [n = 17], adults [n = 175], and older adults [n = 21]). The mean (SD) age was 37 (18), and 86% were male. The mean shock index was 1.1 (0.4) on presentation with a median [IQR] Glasgow Coma Scale of 4 [3-14], and 22.1% had a prehospital cardiac arrest. The study population was profoundly injured with a median injury severity scoreand chest-abbreviated injury scale of 26 [17-38] and 4 [3-5], respectively, with lung (76.5%) being the most injured intrathoracic organs. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 22.5%, 33%, and 53%, respectively, and 51% developed major complications. There was no significant difference in terms of in-hospital mortality (P = 0.800) and major complications (0.416) among pediatrics, adults, and older adults. CONCLUSIONS: One in three patients undergoing TDCS die within the first 24 h, and more than half of them develop major complications and die in the hospital, with no difference among pediatric, adults, and older adults. Future efforts should be directed to improve the survival of these severely injured, metabolically depleted, challenging patients.

Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database.

INTRODUCTION: Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS: We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS: There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS: There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.

The role of emergency department thoracotomy in patients with cranial gunshot wounds.

BACKGROUND: Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS: We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains. RESULTS: Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSION: Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Surgical stabilization of traumatic rib fractures is associated with reduced readmissions and increased survival.

BACKGROUND: Surgical stabilization for rib fractures (SSRF) in trauma patients remains controversial, with guidelines currently suggesting the procedure for only select patient groups. How surgical stabilization for rib fractures affect hospital readmission in patients with traumatic rib fractures is unknown. We hypothesized that surgical stabilization for rib fractures would not decrease the risk of readmission. METHODS: The National Readmission Database was examined for adults with any rib fractures from 2010 to 2017. Readmission up to 90 days was examined. Patients receiving surgical stabilization for rib fractures were compared with those receiving nonoperative treatment. RESULTS: In total, 864,485 patients met criteria, with 13,701 (1.6%) receiving SSRF. For patients receiving SSRF, 338 (1.5%) were readmitted. Readmitted patients had higher Charlson Comorbidity Index and were more likely to have flail chest. On multivariate propensity score-matched analysis, SSRF (Hazard Ratio [HR]: 0.55, 95% confidence interval [CI] 0.33-0.92, P = .022) was associated with reduced readmission. Addition of surgical stabilization for rib fractures to video-assisted thoracoscopic surgery (VATS) (Odds Ratio [OR]: 0.95, 95% CI 0.52-1.73, P = .86) or thoracotomy (OR: 1.97, 95% CI 0.83-4.70, P = .13) was not associated with increased readmission. On further propensity matched analysis, VATS + SSRF when compared with SSRF alone (HR: 0.75, 95% CI 0.18-3.20, P = .696), and VATS + SSRF when compared with VATS alone (HR: 0.49, 95% CI 0.11-2.22, P = .355) was also not associated with increased readmission. SSRF on primary admission was associated with increased in-hospital survival (HR: 0.27, 95% CI 0.22-0.32, P < .001). For patients with retained hemothorax who underwent VATS, addition of SSRF did not improve survival (HR = 0.92, 95% CI 0.58-1.46, P = .72). However, for patients requiring thoracotomy for retained hemothorax, concomitant SSRF was associated with improved survival (HR = 0.14, 95% CI 0.06-0.32, P < .001). CONCLUSION: Surgical stabilization for rib fractures is associated with reduced readmission risk while also being associated with improved survival. Patients who had a thoracotomy for retained hemothorax appear to especially benefit from concomitant surgical stabilization for rib fractures.

Prehospital continuous vital signs predict need for resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy prehospital continuous vital signs predict resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Rapid triage and intervention to control hemorrhage are key to survival following traumatic injury. Patients presenting in hemorrhagic shock may undergo resuscitative thoracotomy (RT) or resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjuncts to rapidly control bleeding. We hypothesized that machine learning along with automated calculation of continuously measured vital signs in the prehospital setting would accurately predict need for REBOA/RT and inform rapid lifesaving decisions. METHODS: Prehospital and admission data from 1,396 patients transported from the scene of injury to a Level I trauma center via helicopter were analyzed. Utilizing machine learning and prehospital autonomous vital signs, a Bleeding Risk Index (BRI) based on features from pulse oximetry and electrocardiography waveforms and blood pressure (BP) trends was calculated. Demographics, Injury Severity Score and BRI were compared using Mann-Whitney-Wilcox test. Area under the receiver operating characteristic curve (AUC) was calculated and AUC of different scores compared using DeLong's method. RESULTS: Of the 1,396 patients, median age was 45 years and 68% were men. Patients who underwent REBOA/RT were more likely to have a penetrating injury (24% vs. 7%, p < 0.001), higher Injury Severity Score (25 vs. 10, p < 0.001) and higher mortality (44% vs. 7%, p < 0.001). Prehospital they had lower BP (96 [70-130] vs. 134 [117-152], p < 0.001) and higher heart rate (106 [82-118] vs. 90 [76-106], p < 0.001). Bleeding risk index calculated using the entire prehospital period was 10× higher in patients undergoing REBOA/RT (0.5 [0.42-0.63] vs. 0.05 [0.02-0.21], p < 0.001) with an AUC of 0.93 (95% confidence interval [95% CI], 0.90-0.97). This was similarly predictive when calculated from shorter periods of transport: BRI initial 10 minutes prehospital AUC of 0.89 (95% CI, 0.83-0.94) and initial 5 minutes AUC of 0.90 (95% CI, 0.85-0.94). CONCLUSION: Automated prehospital calculations based on vital sign features and trends accurately predict the need for the emergent REBOA/RT. This information can provide essential time for team preparedness and guide trauma triage and disaster management. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Predictive Factors and Outcomes for Successful Thoracoscopic Lung Resection in Pediatric Patients.

BACKGROUND: Less than 50% of children with congenital lung lesions are treated thoracoscopically. There are variable data regarding the benefits and limited information on factors contributing to successful thoracoscopic lobectomies in pediatric patients. We sought to identify predictive factors leading to safe and efficient thoracoscopic lung resection. STUDY DESIGN: We performed a single-center, retrospective chart review of patients (age <18 y) who underwent lung resection between June 2009 and July 2020. Pulmonary wedge resection was excluded. Data collected included demographics, perioperative findings, such as symptoms or infection, and postoperative outcomes. Univariate, multivariate, and sensitivity analyses were performed. RESULTS: Ninety-six patients were identified. Sixty-nine patients (72%) underwent initial thoracoscopy, with 15 (22%) converting to open thoracotomy (CTO). Forty-one (43%) patients had preoperative symptoms and 15 (15.6%) had an active infection. Among symptomatic patients, 18 (43.9%) underwent thoracotomy and 23 (56%) were attempted thoracoscopically, 13 (31%) of whom were completed thoracoscopically. On univariate analysis, age >1 year, infection, preoperative symptoms, and intraoperative adhesions were associated with CTO. Older age (odds ratio [OR] = 1.041) and estimated blood loss (EBL) (OR = 2.398) were significant prognostic factors of CTO on logistic regression. Thoracoscopy was significantly associated with decreased length of stay, opioid use, chest tube duration, blood loss and need for blood transfusion. There was no difference in operative time, 30-day readmission, or mortality. CONCLUSIONS: Thoracoscopy has become a standard approach for pediatric lung resection. Our findings indicate that age < 1 year and the absence of active respiratory infection and preoperative symptoms may be predictive of successful completion of the thoracoscopic approach. Thoracoscopy offers significant advantages over the traditional open thoracotomy with regard to blood loss and opioid requirements, LOS, and chest tube duration.

Comparative Effectiveness of Surgical Approaches for Lung Cancer.

BACKGROUND: The magnitude of association and quality of evidence comparing surgical approaches for lung cancer resection has not been analyzed. This has resulted in conflicting information regarding the relative superiority of the different approaches and disparate opinions on the optimal surgical treatment. We reviewed and systematically analyzed all published data comparing near- (30-d) and long-term mortality for minimally invasive to open surgical approaches for lung cancer. METHODS: Comprehensive search of EMBASE, MEDLINE, and the Cochrane Library, from January 2009 to August 2019, was performed to identify the studies and those that passed bias assessment were included in the analysis utilizing propensity score matching techniques. Meta-analysis was performed using random-effects and fixed-effects models. Risk of bias was assessed via the Newcastle-Ottawa Scale and the ROBINS-I tool. The study was registered in PROSPERO (CRD42020150923) prior to analysis. RESULTS: Overall, 1382 publications were identified but 19 studies were included encompassing 47,054 patients after matching. Minimally invasive techniques were found to be superior with respect to near-term mortality in early and advanced-stage lung cancer (risk ratio 0.45, 95% confidence interval [CI] 0.21-0.95, I2 = 0%) as well as for elderly patients (odds ratio 0.45, 95% CI 0.31-0.65, I2 = 30%), but did not demonstrate benefit for high-risk patients (odds ratio 0.74, 95% CI 0.06-8.73, I2 = 78%). However, no difference was found in long-term survival. CONCLUSIONS: We performed the first systematic review and meta-analysis to compare surgical approaches for lung cancer which indicated that minimally invasive techniques may be superior to thoracotomy in near-term mortality, but there is no difference in long-term outcomes.

Penetrating thoracic injuries: a retrospective analysis from a French military trauma centre.

BACKGROUND: Penetrating thoracic injuries (PTIs) is a medicosurgical challenge for civilian and military trauma teams. In civilian European practice, PTIs are most likely due to stab wounds and mostly require a simple chest tube drainage. On the battlefield, combat casualties suffer severe injuries, caused by high-lethality wounding agents.The aim of this study was to analyse and compare the demographics, injury patterns, surgical management and clinical outcomes of civilian and military patients with PTIs. METHODS: All patients with PTIs admitted to a Level I Trauma Centre in France or to Role-2 facilities in war theatres between 1 January 2004 and 31 May 2016 were included. Combat casualties' data were analysed from Role-2 medical charts. The hospital manages military casualties evacuated from war theatres who had already received primary surgical care, but also civilian patients issued from the Paris area. During the study period, French soldiers were deployed in Afghanistan, in West Africa and in the Sahelo-Saharan band since 2013. RESULTS: 52 civilian and 17 military patients were included. Main mechanisms of injury were stab wounds for civilian patients, and gunshot wounds and explosive fragments for military casualties. Military patients suffered more severe injuries and needed more thoracotomies. In total, 29 (33%) patients were unstable or in cardiac arrest on admission. Thoracic surgery was performed in 38 (55%) patients (25 thoracotomies and 13 thoracoscopies). Intrahospital mortality was 18.8%. CONCLUSION: War PTIs are associated with extrathoracic injuries and higher mortality than PTIs in the French civilian area. In order to reduce the mortality of PTIs in combat, our study highlights the need to improve tactical en route care with transfusion capabilities and the deployment of forward surgical units closer to the combatants. In the civilian area, our results indicated that video-assisted thoracoscopic surgery is a reliable diagnostic and therapeutic technique for haemodynamically stable patients.

Impact of surgical technique and analgesia on clinical outcomes after lung transplantation: A STROBE-compliant cohort study.

There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL [interquartile range (IQR): 500; 1238], thoracotomy patients had 500 mL [325; 818] (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours, and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.

Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines?

BACKGROUND: Emergency department thoracotomy (EDT) for pediatric patients is uncommon, and practice patterns have not been evaluated. We examined the indications and outcomes for EDT by trauma center designation using a nationwide database. METHODS: Patients 16 years or younger who underwent EDT within 30 minutes of arrival from 2013 to 2016 were identified in the American College of Surgeons National Trauma Data Bank. Patient demographic information, indications for EDT, and outcomes were analyzed. Outcomes were compared between centers with and without pediatric trauma center designation. RESULTS: A total of 114 patients were identified for analysis with a mean ± SD age of 10.3 ± 4.7 years. Patients were predominantly male (69%) with a median Injury Severity Score of 26 (interquartile range, 18-42). Penetrating trauma occurred in 56%. Overall, mortality was 90% and was similar in penetrating and blunt trauma (88% vs. 94%; p = 0.34). There were no survivors among the 53 patients (46%) who arrived with no signs of life. Among the 11 patients (10%) who survived, median length of stay was 26 days (interquartile range, 6-28 days). Overall, 8% of EDT was performed at free-standing pediatric trauma centers, 45% at adult centers, and 47% at combined trauma centers. Mortality rates and indications were similar among trauma centers regardless of designation status. CONCLUSION: In a national population-based data set, the mortality after pediatric EDT is high, and many of these procedures are performed at nonpediatric trauma centers. Regardless of injury mechanism, EDT is not appropriate in children without signs of life on arrival. Pediatric guidelines are needed to increase awareness of the poor outcomes and limited indications for EDT. LEVEL OF EVIDENCE: Therapeutic, level IV.

Guns, scalpels, and sutures: The cost of gunshot wounds in children and adolescents.

BACKGROUND: Firearm injuries are the second leading cause of death among US children. While injury prevention has been shown to be effective for blunt mechanisms of injury, the rising incidence of accidental gunshot wounds, school shootings, and interpersonal gun violence suggests otherwise for firearm-related injuries. The purpose of the study is to describe the incidence, injury severity, and institutional costs of pediatric gun-related injuries in Colorado. METHODS: Pediatric patients (≤18 years), who sustained firearm injuries between 2008 and 2018, were identified from the trauma registries of three pediatric trauma centers in Colorado. Patients were stratified based on age: those younger than 14 years were defined as children and those 15 years to 18 years as adolescents. RESULTS: Our cohort (n = 308) was predominantly male (87%), with a median age of 14 years. The overall mortality rate was 11% (34/308), with significantly fewer children (5%) dying from their injuries when compared with adolescents (14%; p = 0.04). Sixty-five (21%) patients required blood product transfusions, with 23 (7.4%) patients receiving a massive transfusion. Overall, 52% (161/308) required a major operation, with 15% undergoing an exploratory laparotomy. One third (4/13) of the patients who had a thoracotomy in the emergency department survived to hospital discharge. Overall, 14.0% of patients had psychiatric follow-up at both 30 days and 1 year. The readmission rate for complications was 11.6% at 30 days and 14% at 1 year. The total cost of care for all pediatric firearm-related injuries was approximately US $26 million. CONCLUSION: The survivors of pediatric firearm injuries experience high operative and readmission rates, sustain long-term morbidities, and suffer from mental health sequelae. Combining these factors with the economic impact of these injuries highlights the immense burden of disease. This burden may be palliated by a multipronged approach, which includes the development and dissemination of injury prevention strategies and better follow-up care for these patients. LEVEL OF EVIDENCE: Epidemiological, Level III.

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility.

BACKGROUND: Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS: Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS: Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS: The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Penetrating injury to the cardiac box.

BACKGROUND: A penetrating injury to the "cardiac box" is thought to be predictive of an injury to the heart; however, there is very little evidence available to support this association. This study aims to evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury. METHODS: All patients presenting to a Level I trauma center from January 2009 to June 2015 who sustained a penetrating injury isolated to the thorax were retrospectively identified. Patients were categorized according to the location of injury: within or outside the historical cardiac box. Patients with concurrent injuries both inside and outside the cardiac box were excluded. Clinical demographics, injuries, procedures, and outcomes were compared. RESULTS: During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144). CONCLUSION: The role of the cardiac box in the clinical evaluation of a patient with a penetrating injury to the thorax has remained unclear. In this analysis, mechanism is important. Stab wounds to the cardiac box were associated with a higher risk of cardiac injury. However, for GSW, injury to the cardiac box was not associated with a higher incidence of injury. The diagnostic interaction between clinical examination and ultrasound, for the diagnosis of clinically significant cardiac injuries, warrants further investigation. LEVEL OF EVIDENCE: Prognostic study, Level IV, Therapeutic V.

[Short-term results of video-assisted lung cancer surgery in octogenarians]. / Morbi-mortalité de la résection pulmonaire pour cancer par chirurgie vidéo-assistée chez l'octogénaire.

INTRODUCTION: Due to an increase in life expectancy, onco-pulmonologists and thoracic surgeons are more frequently faced with octogenarian patients with lung cancer. In this age group, treatment modalities may need to be revised because of the increasing presence of comorbidities. Surgery remains the reference treatment for early stage disease, but mortality rates and postoperative complications are higher in this group of patients. One of the solutions to reduce the operative risk would be to develop videoassisted thoracoscopic pulmonary resection surgery. The aim of this study was to evaluate the results of this form of lung cancer surgery in octogenarians. METHODS: All patients 80 years old or more who underwent videoassisted lung cancer surgery from 2014 to 2018 at Lyon University Hospital were included. Wedge resections and diagnostic procedures were excluded. RESULTS: Nineteen patients (13 men, 6 women) were included. The median age was 82 years old. All patients had undergone videoassisted lobectomy. Three patients required conversion to thoracotomy (15.8%). All patients underwent complete resection (R0). One patient had N1 lymph node involvement, all others were N0. The postoperative complication rate was 68.4%, the majority of which were grade II of the Clavien classification. Perioperative mortality was 5.3%. CONCLUSIONS: Videoassisted lung cancer resection in a selected population of octogenarians is associated with satisfactory short-term results. It is reasonable to favour minimally invasive techniques in this population, even if the proof of their superiority has not yet been firmly established.

Thoracic dog bite wounds in dogs: A retrospective study of 123 cases (2003-2016).

OBJECTIVE: To report the clinical, radiographic, and surgical findings and determine prognostic factors for outcome in dogs with thoracic dog bite wounds. STUDY DESIGN: Retrospective study. ANIMALS: Client-owned dogs (n = 123). METHODS: Medical records of dogs with thoracic dog bite wounds between October 2003 to July 2016 were reviewed for presenting findings, management, and outcomes. Standard wound management included debridement and sterile probing, extending the level of exploration to the depth of the wound. Univariable and multivariable binary logistic regression were used to assess risk factors for exploratory thoracotomy, lung lobectomy, and mortality. RESULTS: Twenty-five dogs underwent exploratory thoracotomy, including lung lobectomy in 12 of these dogs. Presence of pneumothorax (odds ratio [OR] 25.4, confidence interval (CI) 5.2-123.2, P < .001), pseudo-flail chest (OR 15.8, CI 3.2-77.3, P = .001), or rib fracture (OR 11.2, CI 2.5-51.2, P = .002) was associated with increased odds of undergoing exploratory thoracotomy. Presence of pleural effusion (OR 12.1, CI 1.2-120.2, P = .033) and obtaining a positive bacterial culture (OR 23.4, CI 1.6-337.9, P = .021) were associated with increased odds of mortality. The level of wound management correlated with the length of hospitalization (Spearman rank order correlation = 0.52, P < .001) but was not associated with mortality. CONCLUSION: Dogs that sustained pseudo-flail chest, rib fracture, or pneumothorax were more likely to undergo exploratory thoracotomy. Nonsurvival was more likely in dogs with pleural effusion or positive bacterial culture. CLINICAL SIGNIFICANCE: Presence of pseudo-flail, rib fracture, or pneumothorax should raise suspicion of intrathoracic injury. Strong consideration should be given to radiography, surgical exploration, and debridement of all thoracic dog bite wounds.

Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU®.

AIM OF THE STUDY: Emergency department thoracotomy (EDT) may be the last chance for survival in some severe thoracic trauma. This study investigates a representative collective with the aim to compare the findings in Europe to the international experience. Moreover, the influence of different levels of trauma care is investigated. METHODS: All emergency thoracotomies in patients with an ISS ≥ 9 from TR-DGU (2009-2014) within the first 60 min after arrival were identified. EDTs were identified separately, and mini thoracotomies and drainage systems were excluded. RESULTS: 99,013 patients with sufficient data were observed. 1736 (1.8%) received thoracotomy during their hospital stay. 887 patients had a thoracotomy within the first hour in the emergency department (ED). 52.5% were treated in supraregional trauma centers (STC), 36.4% in regional (RTC) and 11.0% in local trauma centers (LTC). The mortality rates were 39.4% (STC), 20.9% (RTC) and 20.8% (LTC). The overall mortality rate showed no significant differences for blunt (28.2%) and penetrating trauma (31.3%). In case of cardiac arrest in the ED, a survival rate of 4.8% for blunt trauma and 20.7% for penetrating trauma was determined if EDT was carried out. Those patients showed a higher rate in severe thoracic organ injuries due to penetrating trauma but less extrathoracic injuries. CONCLUSION: Just over half of EDTs were performed in STC. Emergency room resuscitation followed by EDT had survival rates of 4.8% and 20.7% for blunt and penetrating trauma patients, respectively.

Quality Gaps and Comparative Effectiveness in Lung Cancer Staging and Diagnosis.

BACKGROUND: Guidelines recommend mediastinal sampling first for patients with mediastinal lymphadenopathy with suspected lung cancer. The objective of this study was to describe practice patterns and outcomes of diagnostic strategies in patients with lung cancer. METHODS: This study included a retrospective cohort of 15,914 patients with lung cancer with T1-3N1-3M0 disease diagnosed from 2004 to 2013 in the National Cancer Institute's Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. Patients who had mediastinal sampling as their first invasive test were classified as guideline consistent; all others were guideline inconsistent. Propensity matching was used to compare the number of tests performed, and multivariable logistic regression was used to compare the incidence of complications. RESULTS: Guideline-consistent care increased from 23% to 34% of patients from 2004 to 2013 (P < .001). Use of endobronchial ultrasound-guided transbronchial needle aspiration increased from 0.1% to 25% of all patients (P < .001), and mediastinal sampling increased from 54% to 64% (P < .0001). Guideline-consistent care was associated with fewer thoracotomies (38% vs 71%; P < .001) and CT scan-guided biopsies (10% vs 75%; P < .001) than guideline-inconsistent care but more transbronchial needle aspirations (59% vs 12%; P < .001). Guideline-consistent care was associated with fewer pneumothoraxes (5.1% vs 22%; P < .001), chest tubes (0.9% vs 4.4%; P < .001), hemorrhages (3.5% vs 5.8%; P < .001), and respiratory failure events (2.7% vs 3.7%; P = .047) than guideline-inconsistent care. Bronchoscopic mediastinal sampling was associated with fewer complications than surgical mediastinal sampling. CONCLUSIONS: Guideline-consistent care with mediastinal sampling first was associated with fewer tests and complications. Quality gaps decreased with the introduction of endobronchial ultrasound-guided transbronchial needle aspiration but persist. Gaps include failure to sample the mediastinum first, failure to sample the mediastinum at all, and overuse of thoracotomy.

Use of Imaging and Diagnostic Procedures After Low-Dose CT Screening for Lung Cancer.

BACKGROUND: Clinical trials have demonstrated a mortality benefit from lung cancer screening by low-dose CT (LDCT) in current or past tobacco smokers who meet criteria. Potential harms of screening mostly relate to downstream evaluation of abnormal screens. Few data exist on the rates outside of clinical trials of imaging and diagnostic procedures following screening LDCT. We describe rates in the community setting of follow-up imaging and diagnostic procedures after screening LDCT. METHODS: We used Clinformatics Data Mart national database to identify enrollees age 55 to 80 year who underwent screening LDCT from January 1, 2016, to December 31, 2016. We assessed rates of follow-up imaging (diagnostic chest CT scan, MRI, and PET) and follow-up procedures (bronchoscopy, percutaneous biopsy, thoracotomy, mediastinoscopy, and thoracoscopy) in the 12 months following LDCT for lung cancer screening. We also assessed these rates in an age-, sex-, and number of comorbidities-matched population that did not undergo LDCT to estimate rates unrelated to the screening LDCT. We then reported the adjusted rate of follow-up testing as the observed rate in the screening LDCT population minus the rate in the non-LDCT population. RESULTS: Among 11,520 enrollees aged 55 to 80 years who underwent LDCT in 2016, the adjusted rates of follow up 12 months after LDCT examinations were low (17.7% for imaging and 3.1% for procedures). Among procedures, the adjusted rates were 2.0% for bronchoscopy, 1.3% for percutaneous biopsy, 0.9% for thoracoscopy, 0.2% for mediastinoscopy, and 0.4% for thoracotomy. Adjusted rates of follow-up procedures were higher in enrollees undergoing an initial screening LDCT (3.3%) than in those after a second screening examination (2.2%). CONCLUSIONS: In general, imaging and rates of procedures after screening LDCT was low in this commercially insured population.

Operative Management of Thoracic Gunshot Wounds: More Aggressive Treatment Has Been Required over Time.

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as "historical" (1973-1975 and 1988-1990) and "modern" (2005-2007 and 2015-2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.