Removal of an impaled knife under thoracoscopic guidance.

Thoracoscopy is being increasingly utilized in stable patients to manage both blunt and penetrating injuries. The case of a patient who presented with a knife impaled in the chest is reported. The knife was able to be removed under thoracoscopic guidance, avoiding thoracotomy.

Primary lymphoepithelioma-like carcinoma of the lung.

Primary lymphoepithelioma-like carcinoma (LELC) of the lung is a neoplasm seen most commonly in the nasopharynx of individuals from south China and Taiwan, and is strongly associated with the Epstein-Barr virus. The case of a 62-year-old Chinese man with a rare primary lung T2N1M0 LELC of the left lower lobe is presented. The lesion was further notable because of the presence of necrotizing granulomatous inflammation. The patient was treated with surgical resection. After it was determined that the neoplasm was of primary lung origin, adjunctive chemotherapy was initiated. The role of adjunctive chemotherapy in this setting is discussed.

Management of traumatic lung injury: a Western Trauma Association Multicenter review.

BACKGROUND: Improved outcomes following lung injury have been reported using "lung sparing" techniques. METHODS: A retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as "minor" (suture, wedge resection, tractotomy) or "major" (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded. RESULTS: One hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores "minor" 3.8 +/- 0.9 vs. "major" 4.3 +/- 0.7, p = 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4-2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality. CONCLUSION: Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.

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.

Anatomical considerations in the surgical management of blunt thoracic aortic injury.

PURPOSE: Blunt aortic injury (BAI) involving the thoracic aorta is usually described as occurring at the isthmus. We hypothesized that injuries 1 cm or less from the inferior border of the left subclavian artery (LSCA) are associated with an increased mortality rate compared with injuries that are more distal. METHODS: A retrospective review of patients admitted with the diagnosis of BAI was performed. Injuries were divided into two groups: group I, injuries that were 1 cm or less from the junction of the LSCA and the thoracic aorta; group II, injuries that were more than 1 cm from the LSCA. Primary outcome measures included cross-clamp time, rupture, and death. RESULTS: In a 14-year period, 122 patients were admitted with BAI. The anatomy relative to the LSCA could be determined in 91 patients who underwent operative repair. Forty-two injuries (46%) were classified as group I, and 49 injuries were classified as group II. Group I injuries were characterized by an increased mortality rate (18/42 or 43% in group I vs 11/49 or 22% in group II, P = .04), intraoperative rupture rate (7/42 or 17% in group I vs 1/49 or 2% in group II, P = .003), and cross-clamp time (39.5 +/- 21.9 minutes in group I vs 28.4 +/- 13 minutes in group II, P = .04). Three ruptures occurred while proximal control was being obtained. CONCLUSION: Increased technical difficulty and risk of rupture characterize injuries that occur proximally in the descending thoracic aorta, 1 cm from the LSCA. These injuries may be better managed by instituting bypass before attempting to obtain proximal control and by routinely clamping proximal to the LSCA.

Right atrial perforation secondary to implantable cardioverter defibrillator insertion.

Implantable cardioverter defibrillator (ICD) placements can be associated with serious complications. This paper reports a patient in whom percutaneous placement of an ICD resulted in a hemopneumothorax. This was due to an active fixation lead that perforated the right atrial wall and injured the adjacent lung parenchyma. The hemothorax was drained thoracoscopically, and the atrial injury was covered with fibrin glue.

Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study.

HYPOTHESIS: It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality. DESIGN: A retrospective case series. SETTING: Five urban trauma centers. STUDY SELECTION: Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy). DATA EXTRACTION: Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated. MAIN OUTCOME MEASURE: Death. RESULTS: One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001). CONCLUSIONS: The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.

Psychiatric disorders affect outcomes of antireflux operations for gastroesophageal reflux disease.

BACKGROUND: Most of the information used to determine a patient's candidacy for antireflux surgery has centered on physiologic measurements of esophageal functioning and quantitative assessment of acid reflux. Unfortunately, little attention has been paid to the study of psychosocial factors that could affect outcomes. The purpose of this study was to establish whether concomitant psychiatric disorders might affect the symptomatic outcomes of antireflux surgery. METHODS: We retrospectively reviewed a prospectively gathered database of patients with gastroesophageal reflux disease (GERD) who underwent either open or laparoscopic antireflux surgery. A history of a psychiatric disorder was considered to be present if the patient had been previously diagnosed with a DSM-IV psychiatric diagnosis and was being medically treated for it. Preoperatively, patients were evaluated with the symptom severity questionnaire, the GERD-HRQL (best score 0, worst score 50). Later in the series, patients were also evaluated with the generic quality-of-life questionnaire, the SF-36 (best score 100, worst score 0). After antireflux surgery, patients completed both questionnaires 6 weeks postoperatively. RESULTS: A total of 94 patients underwent antireflux surgery. Seventy-seven of them had laparoscopic antireflux surgery (either Nissen or Toupet fundoplication), and 17 had open antireflux surgery (Nissen, Toupet, Collis-Nissen, or Belsey fundoplications). Nine patients had psychiatric disorders (five major depression, four anxiety disorders). At 6-week follow-up, 95.3% of patients without psychiatric disorders were satisfied with surgery, as compared to 11.1% of patients with psychiatric disorders (p < 0.000001). Patients satisfied with surgery had a median SF-36 mental health domain score of 76, as compared to a score of 36 for patients dissatisfied with surgery (p = 0.0002). Patients without psychiatric disorders showed improvement in the median total GERD-HRQL score from 27 preoperatively to 1 postoperatively (p < 0.000001), whereas patients with psychiatric disorders demonstrated less improvement, from 30 preoperatively to 10.5 postoperatively (p = 0.03). CONCLUSIONS: Patients with psychiatric disorders are rarely satisfied with the results of antireflux surgery. Moreover, these patients demonstrated less symptomatic relief than patients without psychiatric disorders. Patients who were dissatisfied with antireflux surgery--even those without psychiatric disorders--had lower scores on the SF-36 mental health domain. These results suggest that even patients who might otherwise be candidates for antireflux surgery may have a poor symptomatic outcome, if they also have low mental health domain scores. Antireflux surgery in patients who suffer from major depression or anxiety disorder should be approached with great trepidation.

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.

Treatment of pulmonary artery compression due to fibrous mediastinitis with endovascular stent placement.

We present the case of a 32-year-old woman with high-grade right pulmonary artery stenosis secondary to fibrous mediastinitis. The patient was managed with balloon angioplasty and stent placement. Only 15 cases of this nature have been reported in the literature, and this is one of the first to be managed with endovascular stent placement.

Choice of venous cannulation for bypass during repair of traumatic rupture of the aorta.

BACKGROUND: Choices for venous cannulation for left heart bypass, to assist repair of traumatic rupture of the thoracic aorta, are between the left atrial appendage and pulmonary veins. METHODS: A retrospective chart review was performed of patients who underwent operative repair of ruptured aorta. RESULTS: Over a 15-year period between March 1985 and February 2000, 133 patients were admitted to a level I trauma center with aortic rupture. Of the 50 procedures performed with left heart bypass, the left atrial appendage was cannulated in 19 and pulmonary veins in 31 (four superior, 27 inferior). Complications occurred in 7 of the 19 patients who underwent venous cannulation via the atrial appendage (two ventricular fibrillation, three atrial fibrillation, one pericardial effusion leading to tamponade, and one phrenic nerve injury). Complications occurred in 2 patients who underwent cannulation via pulmonary vein (one atrial fibrillation, one pericardial effusion requiring tapping) (p = 0.02). CONCLUSIONS: Cannulation via the pulmonary veins is associated with a decrease in complication rates compared with cannulation of the atrial appendage.

Impact of presenting physiology and associated injuries on outcome following traumatic rupture of the thoracic aorta.

We hypothesized that the predominant factor influencing outcome of traumatic rupture of the thoracic aorta (TRA) was the degree of shock on presentation and associated injuries. We reviewed our experience with TRA over a 15-year period. Patients were classified as "unstable" if presenting systolic blood pressure was <90 mm Hg or if it decreased to <90 mm Hg after admission. We determined the presence of closed head injury, cardiac risk factors, a preoperative acute lung injury (ALI). The influence of these factors on mortality, postoperative adult respiratory distress syndrome (ARDS), and paralysis was analyzed. One hundred thirty-six patients were admitted with TRA. One hundred twenty underwent operative repair with a mortality of 31 per cent. Operative mortality was significantly higher in unstable patients (62%) versus stable patients (17%, P = 0.001), in patients with cardiac risk factors (71%) versus those without (24%, P = 0.001), and in patients with preoperative free rupture (83%) with versus those without (19%, P = 0.001). Free rupture was the cause of hypotension in only 10 of 42 unstable patients, with the remainder being due to other causes. Preoperative ALI was associated with a marked increase in postoperative ARDS (47% with vs 9% without, P = 0.001) but not operative mortality. Mechanical circulatory support (MCS) was used in 59 cases, none of whom experienced paralysis, whereas eight of 61 operated on without MCS developed paralysis (P = 0.001). When logistic regression was applied the use of MCS was not determined to be statistically significant. However, preoperative instability was found to be a significant predictor of postoperative paralysis with the risk being increased 5.5 times (confidence interval 3.3-10). The predominant factor influencing mortality, postoperative ARDS, and paralysis was preoperative instability and associated injuries. In patients who are hypotensive, other injuries should take precedence over repair of TRA. Patients who are stable but who have cardiac or pulmonary risk factors may be better managed by a period of nonoperative management until their condition improves.

Surgical management of paraesophageal hernias: outcome and quality of life analysis.

BACKGROUND: Paraesophageal hernias (PEHs) have protean clinical manifestations, and a variety of surgical approaches may be appropriate. We report both surgical and quality-of-life (QoL) outcomes for PEH repairs. METHODS: All patients undergoing elective repair of PEHs were evaluated preoperatively for symptoms and the radiologic appearance of the PEH. In addition, patients undergoing elective repair completed the SF-36, a generic QoL instrument, preoperatively and postoperatively. Short-term postoperative complications were recorded. Symptomatic outcomes and QoL outcomes were assessed. RESULTS: Over a 50-month period, 44 PEH repairs were completed. 3 patients represented emergently - 2 with gastric ischemia, 1 with frank gastric necrosis. The most common presenting symptoms were heartburn (48%), chest pain (27%), abdominal pain (20%), regurgitation (20%), dysphagia (18%), and microcytic anemia (18%). Only 4 patients (9%) were truly asymptomatic. 31 repairs were attempted laparoscopically, 5 were converted to open procedures. There were no gastric or esophageal perforations. 91% of patients had resolution of preoperative symptoms. The only death was in a patient with gastric necrosis. 5 of 8 patients treated by crural repair without fundoplication developed postoperative heartburn. Patients treated laparoscopically had superior QoL scores than patients treated by open surgery in the domains of physical functioning (90 vs. 65), role-physical (100 vs. 0), role-emotional (100 vs. 66.7), vitality (80 vs. 55), and social functioning (100 vs. 75). However, there were 3 symptomatic recurrences in the laparoscopic group (11.5%), all in patients with large, type-III hiatal hernias. CONCLUSIONS: PEH is a potentially life-threatening disease. Although most can be repaired laparoscopically, specific principles must be individualized to each patient to minimize complications and recurrences. A fundoplication should be added to all repairs. Laparoscopic repairs can produce superior QoL results: however, patients with large, type-III hernias may not be appropriate candidates for laparoscopic repair.

Role of bronchoscopy in massive hemoptysis.

Airway hemorrhage is a potentially rapidly fatal condition. Death may occur within minutes from asphyxiation before control can be achieved. The primary prognostic factors are the rate of bleeding and the underlying cardiopulmonary status of the patient. Bronchoscopy is central in management, but the goals differ, depending on circumstances. In stable patients who have minimal hemoptysis, bronchoscopy can diagnose the cause specifically and be used as the primary treatment modality. In the setting of massive or life-threatening bleeding, bronchoscopy primarily is performed to maintain ventilation and to direct endobronchial blockade. Although flexible bronchoscopy is an acceptable mode initially, there should be no delay in performing rigid bronchoscopy when it becomes apparent that bleeding is too vigorous to permit [figure: see text] successful airway exploration with the smaller flexible instrument. Once isolation of bleeding has been achieved, the choice must be made between embolization, surgical resection, or both of these procedures.

Surgical management of lung gangrene.

OBJECTIVE: To review the outcomes of five cases of pulmonary resection for lung gangrene. DESIGN: A retrospective chart review. SETTING: A tertiary referral centre. POPULATION STUDIED: Five patients who underwent pulmonary resection for lung gangrene between April and December 1999. MAIN RESULTS: Pathological confirmation of lung gangrene was obtained in all cases. Three patients were ventilator dependent. All five patients had ongoing sepsis despite antibiotic therapy. Additional indications for resection included bronchopleural fistula (two patients), empyema (three patients) and hemoptysis (one patient). In two cases, there was evidence of bilateral, diffuse necrotizing pneumonia, while in three cases the process was localized to one side. Computed tomography revealed cavitation in four cases and the absence of blood supply to the affected lung in one case. Surgical resection included wedge resection (one patient), lobectomy (two patients), bilobectomy (one patient) and pneumonectomy (one patient). In all cases, the bronchial stump was reinforced with an intercostal flap. Postoperative empyema occurred in two cases, one treated by thoracoscopic decortication, the other by percutaneous drainage. There were no instances of stump leak and no deaths. One patient remains ventilator dependent. CONCLUSIONS: Resection for lung gangrene is possible even in the setting of diffuse parenchymal changes and ventilator dependency. A computed tomography scan of the chest is important to make the diagnosis of lung gangrene and to plan operative management. Reinforcement of the bronchial stump is critical.