[The Patient with Chest Trauma: Surgical Management]. / Der Patient mit Thoraxtrauma: chirurgische Versorgung.

Even though isolated cases of penetrating chest wounds are exceptionally rare in Germany, chest trauma accounts for major morbidity and mortality in over 18 0000 multitrauma patients encountered every year. Injuries range from immediately fatal cardiac wounds and major vessel lacerations to intercostal bleeding, parenchymal damage, chronic haematothorax and secondary empyema. Placement of large-bore chest tubes constitutes a sufficient treatment for most of these pathologies. In select cases further treatment either by minimally invasive techniques (VATS) or conventional thoracotomy is warranted.

Quick proximal arch replacement with moderate hypothermic circulatory arrest.

BACKGROUND: The aim of this study is to evaluate the safety of proximal arch repair using only moderate hypothermic circulatory arrest (HCA) at a temperature of 25 degrees C to 28 degrees C without any adjunctive cerebral protection in comparison with those with moderate HCA and selective cerebral perfusion. METHODS: Thirty patients who underwent proximal arch repair using moderate HCA without selective cerebral perfusion (SCP) were retrospectively examined and defined as the SCP (-) group. As a control group, 31 patients who underwent moderate HCA and SCP within 10 minutes were included in this study and defined as the SCP (+) group. RESULTS: Mean circulatory arrest time was 9.4 +/- 0.8 minutes and 7.5 +/- 1.8 minutes (p = 0.0001) and mean nasopharyngeal temperature at the induction of the circulatory arrest was 26.0 +/- 1.2 degrees C and 26.8 +/- 1.3 degrees C (p = 0.014) in the SCP (+) group and SCP (-) group, respectively. Operative mortality was 3.2% in the SCP (+) group and 3.3% in the SCP (-), and neurologic complications were found in three (9.7%) patients in the SCP (+) group and two (6.7%) patients in the SCP (-) group (p = 0.69). CONCLUSIONS: It was possible to perform proximal arch replacement in selected patients using moderate HCA without any adjunctive cerebral protection with excellent results, and no advantage of the use of SCP was found in patients who required short HCA for proximal arch replacement.

The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis.

OBJECTIVE: There is no common guideline on what temperature should be achieved at the lower body circulatory arrest followed by the initiation of selective cerebral perfusion. METHODS: Between October 1999 and August 2005, a total of 377 patients underwent repair of the aortic arch with selective cerebral perfusion and hypothermic circulatory arrest at 20 degrees C to 28 degrees C and were divided into two groups: (1) 125 patients with deep lower body circulatory arrest at 20 degrees C to 24.9 degrees C (deep lower body circulatory arrest group) and (2) 252 patients with moderate lower body circulatory arrest at 25 degrees C to 28 degrees C (moderate lower body circulatory arrest group). To compensate for the differences in patient characteristics, we used a propensity score matching analysis, and comparable patients, 92 patients from each group, were identified for final analysis. RESULTS: There were no significant differences in mortality or morbidity between deep and moderate lower body circulatory arrest, in either the entire study cohort or the propensity-matched cohort. C-reactive protein level 1 day after the operation approached but fell short of significance (108.4 +/- 47.7 mg/L in deep lower body circulatory arrest group and 95.8 +/- 44.2 mg/L in moderate lower body circulatory arrest group, P = .07). The mean temperatures at the initiation of lower body circulatory arrest were 24.1 degrees C +/- 2.2 degrees C in patients who underwent reexploration for bleeding and 24.9 degrees C +/- 1.8 degrees C in patients who did not (P = .025); the difference also reached statistical significance in multivariate analysis (P = .046, odds ratio 0.796). CONCLUSIONS: Our results suggest that moderate lower body circulatory arrest can be safely performed for aortic arch repair. In fact, postoperative inflammatory response tended to be lower in patients with moderate lower body circulatory arrest than those with deep lower body circulatory arrest, and deep lower body circulatory arrest was a strong risk factor for reexploration for bleeding.