Blunt Pharyngoesophageal Injuries: Current Management Strategies.

BACKGROUND:: Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration. METHODS:: The National Trauma Databank datasets 2007-2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay. RESULTS:: A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p < 0.01) and need for intensive care unit admission (75% vs 31%, p < 0.01). The overall mortality was 2%: 3.1% for neck explorations versus 1.6% for conservative management (adjusted p = 0.54). Neck exploration patients were more likely to remain longer in the hospital (median 13 vs 10 days, adjusted p = 0.03). CONCLUSION:: Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.

Surgical intensive care in the nonagenarian. No basis for age discrimination.

OBJECTIVE: To investigate the effect of extreme age on outcome from surgical intensive care. DESIGN: Prospective data collection. SETTING: A 20-bed noncardiac surgical intensive care unit (SICU) that admits 2200 patients per year from a 1201-bed tertiary medical center. PATIENTS: Nonagenarians were compared with patients under 90 years of age over a 33-month period. Seven patients over age 100 years and 77 nonsurgical patients were excluded. MAIN OUTCOME MEASURES: Mortality and length of stay were determined for both the SICU and the entire hospitalization. The nonagenarian and younger groups were stratified by severity of illness using the first-day Simplified Acute Physiology Score (SAPS). RESULTS: One hundred forty nonagenarian patients (mean +/- SE age, 92.1 +/- 0.2 years) were compared with 5652 younger patients (mean age, 60.1 +/- 0.3 years). The mean SAPS of 11.1 for nonagenarian patients was significantly higher than the SAPS of 8.6 for younger patients (P < .001). Mortality in the SICU was 4.3% for nonagenarian patients vs 2.3% for younger patients (P = .13). SICU mortality rose with increasing SAPS in both groups, but there was no significant difference between nonagenarian and younger patients for any SAPS group. Hospital mortality differed significantly, with 17.1% for nonagenarian patients and 5.3% for younger patients (P < .001). Hospital and SICU length of stay did not differ significantly between the groups. CONCLUSIONS: Nonagenarians do not differ from younger SICU patients in survival from SICU care, although hospital mortality is greater in nonagenarians. Age alone should not be used to make decisions about the utility of SICU care for the elderly. Outcome correlates better with severity of illness, and the measure is valid in young and old alike.

Laparoscopic common bile duct exploration: long-term outcome.

HYPOTHESIS: Transcystic laparoscopic common bile duct exploration (LCBDE) with biliary endoscopy results in excellent long-term clinical outcome and patient satisfaction. DESIGN: Prospective cohort study of unselected patients found to have common bile duct stones during laparoscopic cholecystectomy between October 1989 and April 1998. A mailed survey assessed symptoms, outcome, and satisfaction. SETTING: A large community teaching hospital. PATIENTS: Two hundred seventeen patients with common bile duct stones. INTERVENTION: Transcystic LCBDE with choledochoscopy. MAIN OUTCOME MEASURES: Success of LCBDE, morbidity, postoperative symptoms, and satisfaction. RESULTS: One hundred sixteen surveys (54%) were returned. Mean follow-up was 60 months. The LCBDE procedure failed in 6 patients and endoscopic retrograde cholangiopancreatography was performed in 4 patients (3%). One patient had unsuspected retained stones. No patient had late recognition of retained stones or a bile duct stricture. Abdominal pain was present in 90 patients (89%) preoperatively and in 29 patients (26%) postoperatively (P = .001). The LCBDE procedure reduced 3 specific pain profiles: epigastric, from 47% (n = 54) to 7% (n = 8); back, from 31% (n = 36) to 6% (n = 7); and shoulder, from 18% (n = 21) to 2% (n = 2). When pain persisted, it was different in character in 15%. All nonpain symptoms (such as nausea, bloating, indigestion, and gas) were reduced from 78% (n = 91) to 34% (n = 39) (P = .001) except diarrhea. Diarrhea was present in 24 patients (22%) preoperatively and postoperatively, though it was a new postoperative symptom in 11 patients (11%). One hundred two patients (95%) were satisfied or mostly satisfied with LCBDE. CONCLUSIONS: Pain and nonpain symptoms, while reduced significantly after LCBDE, may persist. The LCBDE procedure does not result in common bile duct strictures or a significant rate of retained stones. This relatively new treatment for common bile duct stones is safe and effective.

Pedestrian-motor vehicle trauma: an analysis of injury profiles by age.

BACKGROUND: Pedestrian-motor vehicle trauma (PMVT) is a common mechanism of injury in urban populations. STUDY DESIGN: We performed a retrospective review of 273 PMVT victims (16 percent of all patients with blunt injuries) seen at a Level I trauma center over a three-year period. Patients were analyzed by age and grouped as children (age younger than 16 years), adults (age 16 to 59 years), or elderly (age older than 59 years). RESULTS: Children constituted 27 percent of the patients, adults 54 percent, and elderly 19 percent. This mixture had significantly more children and elderly than the population at large or the entire blunt trauma population at our hospital. The majority of patients (66 percent) were male, with females outnumbering males only in the elderly group. Elderly patients were more frequently admitted to the intensive care unit (ICU) and had significantly longer ICU and hospital stays. Injury Severity Scores were successively higher in each age group and significantly higher in the elderly. Extremity trauma was most common in all three groups, followed by head injuries. The elderly patients were more prone to chest and pelvic injuries and the children most often had femur fractures. Operations were performed in 22 percent of the patients; orthopedic procedures were most frequent. The mortality rate was 6 percent, with 69 percent of the deaths occurring during the initial resuscitation efforts. The mortality rate was significantly higher in the elderly patients (13 percent). The majority of accidents occurred during nighttime hours, especially in the adult group. Half of the accidents occurred on the weekend, with the greatest number on Saturday. One-third of the accidents occurred during the months of October to December. CONCLUSIONS: Pedestrian-motor vehicle trauma is a common injury, with distinct epidemiological features that may be useful in accident prevention strategies.

Early postoperative enteral feeding increases anastomotic strength in a peritonitis model.

BACKGROUND: Tumor necrosis factor alpha (TNF-alpha) has been shown to decrease collagen synthesis and increase collagenase activity leading to impaired wound healing. Our hypothesis was that immediate postoperative feeding would decrease TNF-alpha, therefore increasing anastomotic healing in a peritonitis model. METHODS: Twelve Sprague-Dawley rats underwent cecal ligation and puncture to induce peritonitis. Six hours after induction of peritonitis an ileocecectomy and ileocolostomy was performed. Group 1 animals (n = 6) had immediate access to food and water, whereas group 2 (n = 6) had free access to water only. At 48 hours, weight loss, nitrogen loss, anastamotic bursting strength (ABS), TNF-alpha, interleukin-6 (IL-6), and IL-10 were measured. RESULTS: Weight loss was similar in the two groups. Group 1 rats had a significantly lower mean TNF-alpha level (17.3 +/- 10 versus 17.3 +/- 10 mcg/Dl, P = 0.05). ABS was also significantly higher in group 1 rats when compared with group 2 rats (81 +/- 34 versus 39 +/- 13 mm HG, P = 0.03). CONCLUSIONS: These data suggest that immediate postoperative feeding results in a beneficial change in the cytokine profile.

Peptic ulcers in the elderly is a surgical disease.

BACKGROUND: Operative management for peptic ulcer disease (PUD) has changed significantly over the last 30 years. METHODS: For a 15-year period, records of patients undergoing operative management for peptic ulcer disease were stratified into age groups and examined with respect to presentation, type of operation, and risk factors. RESULTS: In all, 154 patients underwent surgery for PUD during the 1990s. Elderly patients were more likely to require an emergent operation (91%, P = 0.005), present with hemodynamic instability (25%, P = 0.025), and have a longer hospital stay (21 days, P = 0.012). Among the elderly in the 1990s as compared with the 1980s, there was increased use of nonsteroidal anti-inflammatory drugs ([NSAIDs] (49%, P = 0.005), decreased tobacco use (22%, P = 0.014), and less likelihood of postoperative renal failure (6%, P = 0.014). CONCLUSIONS: Elderly patients in the 1990s comprise the majority of cases presenting in a more unstable condition as compared with patients <60 years old, but show similar rates of morbidity and mortality. Elderly patients undergoing surgery for PUD have shown an increase in use of NSAIDs over the last 15 years. The types of procedures have not changed, but operations are more likely to be an emergent basis.

Molten metal burns: early treatment improves outcome.

Molten metal burns have received relatively little attention in the surgical literature. We performed a retrospective chart review of 150 patients who sustained molten metal burns between 1972 and 1997. The injuries all occurred in male foundry workers, most commonly from molten aluminum (60%). The typical accident was that of a splatter spill, creating a full-thickness burn. The mean burn size was 2.3 per cent of the body surface area (range, 0.25-25%). The lower extremities were the most commonly injured areas (85%), yet 37 per cent of patients had multiple sites burned. Patients were often initially treated nonoperatively and then referred to a surgeon when the wound failed to heal. Hospitalization was necessary in 89 patients at a mean of 16 days after the injury, and 92 patients required an operation, most commonly excision of the wound with skin grafting. The mean length of hospital stay was 11.2 days, and mean absence from work was 72.6 days. Fifty-one patients treated by the burn surgeon within 2 weeks of injury had a mean length of disability significantly shorter than those referred late (53.5 vs. 83.4 days; P < 0.05). We believe that an underestimation of the severity of these burns often leads to a delay in correct therapy and extends disability.

Laparoscopic cholecystectomy in critically ill cardiac patients.

From August 1989 to January 1993, the authors performed laparoscopic biliary operations in 900 patients, 13 of whom had severe cardiac dysfunction. Nine patients were Goldman Class IV, and four patients were Goldman Class III. Three patients had recent myocardial infarction, five patients were known to have low left ventricular ejection fractions (10%, 21%, 25%, 26%, and 30%), one had severe myocardial ischemia, one had severe congestive heart failure, and one was in profound shock. Nine patients underwent successful laparoscopic cholecystectomy. Laparoscopic cholecystostomies were performed in three patients. One operation was converted to an open cholecystectomy. There was one death within 30 days of surgery. With appropriate hemodynamic monitoring and adequate perioperative support of cardiac function, laparoscopic cholecystectomy can be performed safely for acute cholecystitis in patients with severe cardiac disease. When compared with historical controls, laparoscopic cholecystectomy appears to be safer than open cholecystectomy.

Relationship of hyperglycemia and severity of illness to neurologic outcome in head injury patients.

Hyperglycemia upon hospital admission has been associated with poorer neurologic outcomes in patients with brain injury, but this relationship has not been well defined. To evaluate the relationship of hyperglycemia and severity of illness to neurologic outcome, the authors examined Surgical Intensive Care Unit (SICU) records for a 6 month period at a Level I trauma center. Of 276 trauma admissions, 97 patients had intracranial injuries. The peak glucose determination on the first day of admission was correlated with the Glasgow Coma Scale (GCS) score upon admission and discharge from the SICU and with severity of illness as measured by the Simplified Acute Physiology Score (SAPS). The mean admission GCS was 10.6 (+/- 0.49 S.E.M.), the mean glucose on the first SICU day was 146 (+/- 7.7 S.E.M.), and the mean peak glucose was 176 (+/- 8.2 S.E.M.). The peak glucose was inversely related to both GCS on admission and GCS at discharge (P < 0.001). However, stepwise multiple regression analysis revealed that the best single predictor of GCS at discharge was the GCS on admission. The next best predictor was the SAPS on the first SICU day. Peak glucose did not add to the power of admission GCS and SAPS to predict neurologic outcome. Peak glucose levels in brain-injured patients may simply reflect severity of illness and injury that is better represented by SAPS.

Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury.

Splenosis represents the autotransplantation of splenic tissue after splenic trauma or surgery. Disruption of the splenic capsule causes fragments of splenic tissue to be seeded mainly throughout the peritoneal cavity, where they are characterized by diffusely scattered bluish implants. Extraperitoneal locations are very rare and mainly include the thoracic cavity after thoracoabdominal trauma with simultaneous splenic rupture and diaphragmatic laceration. We retrospectively identified all patients in the pathology registry with the diagnosis of splenosis between December 1974 and July 2003 at our urban teaching hospital. Data collected included presenting signs and symptoms, history, imaging studies, treatment, pathology, and outcome. Five cases of splenosis were identified and described. Location of the splenosis was intraperitoneal in two and intrahepatic, intrathoracic, and subcutaneous in one each. In these cases, there was an average interval of 29 years between splenic injury and diagnosis, and most were found incidentally. One of the cases was managed entirely laparoscopically and another thoracoscopically.

Splenectomy for splenic metastases: a changing clinical spectrum.

Splenic metastases from solid tumors are unusual with only scattered case reports of patients treated with splenectomy before 1987. We conducted a retrospective chart review at our large tertiary-care private teaching hospital between January 1990 and September 1999 and found splenic metastases in 31 patients. In eight patients (26%), the spleen was the only site of metastatic disease. Of the 31 splenectomies for metastases, 23 were performed for ovarian neoplasms, five during primary operative procedures, and 18 during secondary cytoreductive procedures or explorations for late recurrences at an average of 3.9 years after the original operation. Nearly half of the metastases (15 of 31) appeared entirely within the splenic parenchyma, representing probable hematogenous spread, whereas seven involved both the splenic parenchyma and capsule and nine involved the capsule only. Between 1990 and 1999 we identified a statistically significant increase in use of splenectomy for treatment of metastatic tumor with a Spearman rank correlation value of 0.86 (P < 0.05). Most of this increase was attributable to ovarian cancer cases and may be due to expansion of treatment options or improved imaging methods. We report the largest series of splenectomy for splenic metastases and the ninth case report in the world literature of splenectomy for isolated splenic metastasis due to colorectal cancer.

Future shock: trauma in the managed care era.

This study examines the effects of managed care on the treatment of 1724 trauma patients seen over a 2-year period at an urban Level I trauma center. Fifty-one per cent of all trauma patients were insured. Managed care plans represented 42 per cent of the insurance coverage overall, increasing from 39 per cent in the first year to 45 per cent in the second. All treatment was provided by the receiving general surgery trauma team and was rendered independent of insurance status. Eighty per cent of patients completed their hospitalization at the trauma center. Clinical outcome, transfer rates, and mortality were similar regardless of insurance type. We conclude that managed care plans represent a significant and increasing portion of the insurance coverage of trauma patients, and propose that national guidelines should be developed to guarantee quality and continuity of trauma care.

Trauma in the elderly: an analysis of outcomes based on age.

This study evaluated the comparative outcomes of elderly trauma patients admitted to a tertiary Surgical Intensive Care Unit (SICU) over a 5-year period (4/1/87-3/31/92). A total of 289 trauma patients 65 or older (mean age 76.3 +/- 0.4 years) were compared with 1,877 trauma patients under age 65 (mean age 31.4 +/- 0.3). The Simplified Acute Physiology Score (SAPS) severity of illness on admission for elderly trauma patients was 12.2 +/- 0.3, significantly higher than the SAPS of the younger patient group, 7.9 +/- 0.1 (P < 0.0005). Elderly survivors had higher than the SAPS of admission than their younger cohorts, 11.0 +/- 0.3 versus 7.3 +/- 0.1 (P < 0.0005), but there was no significant difference in SAPS for non-survivors. The Injury Severity Score (ISS) of elderly patients, 14.2 +/- 1.0, was not significantly higher than the ISS of younger patients, 12.3 +/- 0.3 (P = 0.06). Thirty-three elderly trauma patients (11.4%) died in the SICU, compared with 90 (4.8%) deaths in younger patients (P < 0.00005). However, when patients were stratified by admission SAPS, SICU mortality was nearly equivalent between the older and younger patient groups. An additional 14 elderly patients (4.8%) died in the hospital after SICU discharge, compared with 9 additional deaths (0.5%) in the younger patient group (P < 0.00005).(ABSTRACT TRUNCATED AT 250 WORDS)

Iatrogenic gallbladder perforation during laparoscopic cholecystectomy: etiology and sequelae.

Iatrogenic perforation of the gallbladder (PGB) during laparoscopic cholecystectomy (LC) leads to spillage of bile and gallstones into the peritoneal cavity, which can result in serious postoperative infection. The objective of this study is to prospectively evaluate with long-term follow-up the risk factors, mechanisms, and complications associated with PGB in patients undergoing LC. Data from 1412 patients undergoing LC were collected prospectively between 1989 and 1995. Patients with and without iatrogenic gallbladder perforation were compared. Long-term follow-up was obtained using mailed questionnaires and telephone interviews, when needed. Of the 1412 patients, 512 (36%) sustained a PGB. Male sex, weight, gallbladder inflammation, thickening of the gallbladder, presence of adhesions, and a difficult hilar dissection were all associated with an increased incidence of PGB. The most common mechanisms of PGB were laceration due to grasper traction (55%) and electrocautery dissection (40%). Both the operating time and length of hospital stay were significantly longer in the PGB group. No difference was observed in the rate of wound infections between PGB and non-PGB patients (1.6% versus 1.8%). Only one patient (with an inflamed and perforated gallbladder) developed an early postoperative intra-abdominal abscess. Long-term follow-up averaging 48 months was achieved with a response rate of 44 per cent. No late intra-abdominal abscesses or complications attributable to retained gallstones were discovered.

Perforated appendicitis is not a contraindication to laparoscopy.

Recent studies have reported an increased risk of intra-abdominal abscess formation following laparoscopic operation for perforated appendicitis. We undertook this study to compare laparoscopic versus open appendectomy in the treatment of perforated appendicitis. Records of all patients undergoing an appendectomy between January 1994 and June 1997 were reviewed, classifying appendicitis as acute, gangrenous, or perforated based on the intraoperative findings. Operative procedures were categorized as open, laparoscopic converted to open, or laparoscopic. The study group included 690 patients; four hundred fourteen (60%) were acute, 77 (11%) were gangrenous, and 199 (29%) were perforated. Although mean length of stay was shorter for all patients undergoing laparoscopic appendectomy, patients with perforated appendicitis had similar length of stay between treatment groups. Mean operative time for open appendectomy was significantly shorter than for converted or laparoscopic appendectomy regardless of diagnosis (P<0.01). Ten patients (1.4%) developed an intra-abdominal abscess: six after open appendectomy (1.7%), one after converted appendectomy (3.7%), and three after laparoscopic appendectomy (1%). There was no significant difference in rate of abscess formation in patients with perforated appendicitis undergoing open, converted, or laparoscopic appendectomy. We conclude that laparoscopic appendectomy for perforated appendicitis is not associated with an increased rate of intra-abdominal abscess formation.

Percutaneous dilatational tracheostomy: still a surgical procedure.

Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1+/-1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.

Bradycardia following carotid endarterectomy.

This study was performed to determine whether bradycardia complicates the postoperative course of patients undergoing carotid endarterectomy (CEA). The records of 216 patients undergoing 233 CEAs over a 2-year period were reviewed. Patients were divided into two groups based on their lowest Surgical Intensive Care Unit (SICU) heart rate (HR). Those with HR < 60 were in the Bradycardic (BRADY) group and those with HR > or = 60 were in the Non-Bradycardic (NON-BRADY) group. One hundred and sixteen patients developed bradycardia, with a mean (+/- SEM) HR of 51.1 +/- 0.5, compared with 117 NON-BRADY patients with a mean HR of 70.6 +/- 0.9 (P < 0.0005). There were no significant differences between the groups in age, use of cardioactive drugs, SICU severity of illness, or length of SICU stay. The systolic blood pressure for BRADY patients averaged 144 +/- 2.2 on admission and 144 +/- 2.2 (P = NS) in the SICU, while that of NON-BRADY patients rose from 143 +/- 2.3 on admission to 156 +/- 2.5 (P = 0.001). Fifty-four patients receiving a second CEA had a SICU HR not significantly different from those patients undergoing a first CEA. Of 17 patients who underwent bilateral CEAs during the study period, SICU HRs averaged 65.1 +/- 3.7 after the first procedure and 64.7 +/- 3.6 after the second (P = NS). The authors conclude that bradycardia following CEA is a frequent but benign postoperative finding that does not affect outcome, cause significant hypotension, or prolong the SICU stay.

Nosocomial pneumonia is not prevented by protective contact isolation in the surgical intensive care unit.

Nosocomial pneumonia (NP) is the leading cause of death from hospital-acquired infection in intubated surgical intensive care unit (SICU) patients. To determine whether protective contact isolation would lower the incidence of NP in intubated patients we performed a prospective, randomized, and controlled study in two SICUs in a tertiary medical center. Over a period of 15 months two identical ten-bed SICUs alternated for 3-month periods between protective contact isolation (isolation group) and standard "universal precautions" (control group). In the isolation group all personnel and visitors donned disposable gowns and nonsterile gloves before entering an intubated patient's room; handwashing was required before entry and on leaving the room. In the control group caregivers utilized only "standard precautions" including handwashing and nonsterile gloves for intubated patients. Respiratory cultures were obtained 48 hours after SICU admission and every 48 hours thereafter until extubation, transfer to floor care, or death. Airway colonization (AC) occurred in 72.7 per cent of isolated patients and 69.0 per cent of control patients (P = 0.61). The incidence of NP was significantly higher in the isolation group (36.4%) compared with the control group (19.5%) (P = 0.02). There was no statistically significant difference between groups in days from SICU admission to AC, days to NP, and mortality. We conclude that protective contact isolation with gowns, gloves, and handwashing is not superior to gloves and handwashing alone in the prevention of AC and NP in SICU patients and may in fact be detrimental.

Continuous intra-arterial oxygen monitoring: accuracy and reliability in the surgical intensive care unit.

The accuracy and reliability of an invasive intra-arterial oxygen sensor catheter was evaluated in 20 critically ill surgical intensive care unit (SICU) patients. All patients required continuous arterial blood pressure monitoring, at least 72 hours of ventilator support, and intermittent arterial blood gas sampling for clinical management. The intra-arterial sensor provided continuous PO2 (PsO2) values on a bedside electronic monitor. PsO2 values were sampled every 60 seconds and automatically stored on a bedside personal computer. Arterial blood gas (ABG) PaO2 values were collected and matched by collection time with corresponding PsO2 values. During 1,238 hours of continuous intra-arterial monitoring, 74,280 PsO2 values and 246 ABG PaO2 values were collected. Of the 246 PaO2 results, 175 (71.3%) had a matching PsO2. Regression of matched PsO2 and PaO2 values yielded a correlation coefficient of 0.58 and standard error of the estimate (SEE) of 33.1 (P < 0.0005). Even though matched PsO2 and PaO2 measurements demonstrated a linear relationship, only 34 per cent of the variation in PsO2 could be attributed to changes in PaO2. Technical sensor or instrument problems affected PsO2 monitoring in 17 of 20 patients and 28 of the 33 sensors tested. The authors conclude that continuous intra-arterial monitoring of PsO2 is a novel idea, but technical issues limit its use in acutely ill, conscious SICU patients.

Video-assisted thoracoscopic surgery in the management of penetrating and blunt thoracic trauma.

BACKGROUND: The role of video-assisted Thoracoscopic Surgery (VATS) is still being defined in the management of thoracic trauma. We report our trauma cases managed by VATS and review the role of VATS in the management of thoracic trauma. MATERIALS AND METHODS: All the trauma patients who underwent VATS from 2000 to 2007 at Cedars-Sinai Medical Center were retrospectively studied. RESULTS: Twenty-three trauma patients underwent 25 cases of VATS. The most common indication for VATS was retained haemothorax. Thoracotomy was avoided in 21 patients. VATS failed in two cases. On an average VATS was performed on trauma day seven (range 1-26) and the length of hospital stay was 20 days (range 3-58). There was no mortality. VATS was performed in an emergency (day 1-2), or in the early (day 2-7) or late (after day 7) phases of trauma. CONCLUSION: VATS can be performed safely for the management of thoracic traumas. VATS can be performed before or after thoracotomy and at any stage of trauma. The use of VATS in trauma has a trimodal distribution (emergent, early, late), each with different indications.