The Mangled Extremity Severity Score Fails to be a Good Predictor for Secondary Limb Amputation After Trauma with Vascular Injury in Central Europe.

BACKGROUND: The Mangled Extremity Severity Score (MESS) was constructed as an objective quantification criterion for limb trauma. A MESS of or greater than 7 was proposed as a cut-off point for primary limb amputation. Opinions concerning the predictive value of the MESS vary broadly in the literature. The aim of this study was to evaluate the applicability of the MESS in a contemporary civilian Central European cohort. METHODS: All patients treated for extremity injuries with arterial reconstruction at two centres between January 2005 and December 2014 were assessed. The MESS and the amputation rate were determined. RESULTS: Seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. The mean MESS was 4.97 (CI 4.4-5.6). Seventy-three per cent of all patients (52/71) had a MESS < 7 and 27% (19/71) of ≥7. Eight patients (11%) underwent secondary amputation. Patients with a MESS ≥ 7 showed a higher, but statistically not significant secondary amputation rate (21.1%; 4/19) than those with a MESS < 7 (7.7%; 4/52; p = 0.20). The area under the ROC curve was 0.57 (95% CI 0.41; 0.73). CONCLUSIONS: Based on these results, the MESS appears to be an inappropriate predictor for amputation in civilian settings in Central Europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft-tissue traumas.

[Extensive emphysema after intramedullary nailing of a pertrochanteric fracture : Life-threatening infection or benign complication]. / Ausgeprägtes Emphysem nach Marknagelung einer pertrochantären Fraktur : Lebensbedrohliche Infektion oder benigne Komplikation.

The development of emphysema after intramedullary nailing can represent an easily manageable complication but in the differential diagnostics it could, however, be a life-threatening infection with Clostridium perfringens. This is a report about the case of an extensive subcutaneous and retroperitoneal emphysema, which developed after intramedullary nailing of a pertrochanteric femoral fracture and where such an infection was suspected.

Clinical Manifestations of Respiratory Bronchiolitis as an Incidental Finding in Surgical Lung Biopsies: A Retrospective Analysis of a Large Austrian Registry.

BACKGROUND: While respiratory bronchiolitis (RB) is a frequent histopathological finding in smoker's lungs, RB-associated interstitial lung disease (RB-ILD) remains a rare disease. OBJECTIVES: We analyzed how the histological finding of RB was associated with clinical information in a series of 684 consecutive surgical lung biopsies. METHODS: Retrospective analysis with delineation of clinical manifestations, smoking habits, pulmonary function test, and blood gas analysis in patients with RB in surgical lung biopsy. In 240 of these biopsies, RB was diagnosed, and in 146 of these cases a full clinical dataset was available. RESULTS: The final diagnosis of these 146 patients was consistent with RB-ILD (n = 18), pulmonary Langerhans cell histiocytosis (n = 7), various ILD (n = 9), spontaneous pneumothorax (n = 43), traumatic pneumothorax (n = 5), lung cancer (n = 41), various benign lung tumors (n = 8), and chronic pulmonary effusion (n = 15). Smoking history was positive in 93% of patients, 72% revealed centrilobular emphysema in their biopsy, and 58% described dyspnea as the main symptom. Amongst these diagnoses there were significant differences in age and smoking habits, but only small distinctions in pulmonary function test and blood gas analysis. Out of the patients with RB-ILD, 17% developed lung cancer in the later course. CONCLUSION: RB is strongly related to smoking, emphysema, and dyspnea and frequently associated with lung cancer. RB-ILD is a rare disease that may represent a considerable risk for lung cancer. Pulmonary function testing and blood gas analysis do not differ between RB-associated diseases. The finding of RB should prompt further diagnostic workup, and in case of RB-ILD, entail regular screening for lung cancer.

Application of Hyperbaric Oxygen Reduce Oxidative Damage of Plasmatic Carbonyl Proteins and 8-OHdG by Activating Glutathion Peroxidase.

BACKGROUND: It is postulated that application of hyperbaric oxygenation may induce the production of radicals after HBO. Higher oxygenation and transport of oxygen increase the mitochondrial energy turnover, whereas inner mitochondrial radical formation decreases. METHODS: Several markers of oxidative stress in healthy volunteers (n = 21), including plasma carbonyl proteins (CP), malondialdehyde (MDA), oxidized LDL (oxLDL), 8-hydroxy-deoxyguanosine (8-OHdG), and erythrocyte glutathione peroxidase (GPx) activity are measured before, during, and after HBO. RESULTS: Median plasma concentrations of CP decreased significantly during HBO compared to CP levels before HBO (from 77.1 to 61.7 pmol/mg; p < 0.001) and increased again after HBO (to 78.1 pmol/mg; p = 0.035). 8-OHdG decreased significantly during HBO (8.1 ng/mL; p < 0.001) and remained constant after HBO (8.1 ng/mL) compared to "before HBO" (9.4 ng/mL). MDA increased significantly from 0.92 µM (before HBO) to 1.26 µM (during HBO, p < 0.01) and decreased again to 1.00 µM (after HBO, p = 0.023). Erythrocyte GPx activity also increased significantly during HBO (26.5 ± 14.7; p = 0.005), but not after HBO (25.6 ± 17.2 IU/mg). A negative correlation was observed between GPx and MDA only during HBO (r = -0.518; p = 0.016). CONCLUSIONS: We assume that higher oxygen consumption decreases, on the one hand, the inner mitochondrial generation of free radicals and, on the other, RONS by activation of detoxifying enzymes like GPx.

Determination of metabolites of 5-hydroxymethylfurfural in human urine after oral application.

5-Hydroxymethylfurfural (5-HMF) is a natural occurring substance taken up by everyday food. In former studies it was shown that 5-HMF is completely decomposed in the body after oral or intravenous application resulting in three main metabolites named 5-hydroxymethylfuroic acid, 2,5-furandicarboxylic acid, and N-(hydroxymethyl)furoyl glycine, and possibly a forth metabolic substance, termed 5-sulphoxymethylfurfural, is formed. Determination is possible via HPLC using a hydrophilic interaction chromatography (HILIC) column with an appropriate gradient system (ACN/ammonium formate 100 mM, pH 2.35). Urine samples were purified by use of an SPE method beforehand working with ScreenA cartridges. This cleaning procedure was validated based on ICH guidelines in terms of linearity, quantification, and detection limit, as well as precision, repeatability, and accuracy. Analysis of real-life samples coming from two healthy probands and one cancer patient, who all received 240 mg 5-hydroxymethylfurfural orally once a day, showed dicarboxylic acid and the glycine conjugate in their urine samples. Recovery of the initial compound in form of transformed metabolites was up to 90% within 48 h. Potentially toxic 5-sulphoxymethylfurfural could not be found.

Biomechanical evaluation of augmented and nonaugmented primary repair of the anterior cruciate ligament: an in vivo animal study.

PURPOSE: The purpose of this study was to evaluate in a sheep model the biomechanical performance of augmented and nonaugmented primary repair of the anterior cruciate ligament (ACL) following transection at the femoral end during a 12-month postoperative observation. METHODS: Forty sheep were randomly assigned to nonaugmented or augmented primary ACL repair using a polyethylene terephthalate (PET) band. At two, six, 16, 26 and 52 weeks postoperatively four sheep in each group were sacrificed and biomechanical testing performed. RESULTS: Compared with nonaugmented primary ACL repair, the PET-augmented repair demonstrated superior biomechanical results from 16 weeks postoperatively onwards in terms of anterioposterior (AP) laxity, tensile strength and ligament stiffness. The augmentation device works as a stress shield during the ligament healing process. The nonaugmented ACL repair also resulted in ligament healing, but the biomechanical properties were at a significantly lower level. CONCLUSION: These results support the previously reported histological findings following augmented primary ACL repair. This animal study on the healing capacity of the ACL may provide some important contributions to how primary healing in certain types of ruptures can be achieved. CLINICAL RELEVANCE: I.

Individualized, multimodal palliative treatment of inoperable esophageal cancer: clinical impact of photodynamic therapy resulting in prolonged survival.

BACKGROUND AND OBJECTIVE: In esophageal carcinoma palliative treatment is often required due to advanced tumor stage or patient-related factors. The main goal of our retrospective single center study was to evaluate the effect of an individualized multimodal palliative treatment, focusing on the efficacy of different treatment options. MATERIALS AND METHODS: Between 1999 and 2009, 640 patients suffering from esophageal carcinoma were referred to our division. Two hundred fifty out of those (39.1%) were treated with palliative intention by using a individualized, multimodal concept including endoscopic dilatation, photodynamic therapy (PDT), endoluminal brachytherapy, external radiation, chemotherapy, stenting, feeding tube, and palliative resection. RESULTS: There were 37 women (14.9%) and 211 men (85.1%). The treatment included PDT in 171 cases (in 118 as first measure), stenting in 124 (38), dilatation in 83 (24), endoluminal brachytherapy in 92 (20), feeding enterostomy in 40 (14), external radiation in 67 (23), chemotherapy in 57 (29), and palliative resection in 3 patients. The mean number of palliative treatments per patient was 2.6. Mean survival time for the collective was 34 months. Distant metastases and nodal positivity were connected with a significantly reduced survival. If PDT was used in the first place, median survival was 50.9 months compared to 17.3 months if other options were used as initial modality (P = 0.012). CONCLUSION: By using an individualized multimodal approach, an acceptable mean survival time can be achieved in advanced esophageal cancer treated with palliative intention. PDT, if used as initial endoluminal treatment in patients without gross tumor infiltration into the mediastinum, the great vessels or the tracheo-bronchial tree, enables a considerable beneficial effect in the palliative setting.

High extracellular levels of cefpirome in unaffected and infected lung tissue of patients.

OBJECTIVES: the objective of the present investigation was to measure the extracellular concentrations of cefpirome in unaffected and infected lung tissue of septic patients. METHODS: a single intravenous dose of 30 mg/kg total body weight of cefpirome was administered to eight patients every 12 h prior to insertion of microdialysis probes into lung tissue. RESULTS: the median (minimum, maximum) peak concentration (C(max)), time to C(max) (T(max)), area under the concentration-time curve from 0 to 4 h (AUC(0-4)) and AUC(0-∞) of unbound cefpirome for unaffected lung were 48 (32, 107) mg/L, 0.83 (0.17, 3.17) h, 117 (60, 177) mg ·â€Šh/L and 182 (80, 382) mg ·â€Šh/L, respectively. The corresponding values for infected lung tissue were 45 (6, 122) mg/L, 1.17 (0.83, 2.83) h, 92 (17, 253) mg ·â€Šh/L and 206 (49, 379) mg ·â€Šh/L, respectively. The median apparent terminal elimination half-lives (t(½z)) of cefpirome were 2.61, 3.05 and 3.39 h for plasma, unaffected lung and infected lung, respectively. The median ratios of the AUC(0)(-∞) for lung to the AUC(0)(-∞) for plasma were 0.63 (0.19, 1.55) and 0.46 (0.32, 0.98) for unaffected and infected lung, respectively. CONCLUSIONS: we provide strong evidence that cefpirome penetrates effectively into the extracellular space fluid of lung tissue. Under steady-state conditions, the median concentrations of cefpirome in plasma, unaffected lung and infected lung exceeded the MICs of the majority of relevant bacteria over the entire dosing interval of up to 12 h after intravenous administration of a dose of 30 mg/kg total body weight.

Method development and validation for the analysis of a new anti-cancer infusion solution via HPLC.

A fast and simple HPLC method has been developed and validated for the quantification of a completely new anti-cancer drug during the manufacturing process. The combination of four compounds including α-ketoglutaric acid, hydroxymethylfurfural, N-acetyl-L-methionine and N-acetyl-L-selenomethionine, administered intravenously, is still in test phase but has already shown promising results in cancer therapy. HPLC separation was achieved on an RP-18 column with a gradient system. However, the highly different concentrations of the compounds required a variation in the detection wavelength within one run. In order to produce a chromatogram where peaks were comparable on a similar range scale, detection at absorption maxima for the two most concentrated components was avoided. After optimization of the gradient program it was possible to detect all four substances within 14 min in spite of their strongly different chemical structure. The method developed was validated for accuracy, repeatability, reproducibility and robustness in relation to temperature and pH of buffer. Linearity as well as the limit of detection and quantification were determined. This HPLC method was found to be precise, accurate and reproducible and can be easily used for in-line process control during the manufacture of the anti-tumour infusion solution.

Extracellular concentrations of fosfomycin in lung tissue of septic patients.

OBJECTIVES: The present investigation explored the ability of fosfomycin to penetrate lung tissue of septic patients by utilizing the microdialysis technique. METHODS: After microdialysis probe insertion into healthy and infected lung tissue, a single intravenous dose of 4 g of fosfomycin was administered. RESULTS: The mean C(max), T(max), AUC(0-4) and AUC(0-infinity) for healthy lung were 131.6 +/- 110.6 mg/L, 1.1 +/- 0.4 h, 242.4 +/- 101.6 mgxh/L and 367.6 +/- 111.9 mgxh/L, respectively. The corresponding values for infected lung were 107.5 +/- 60.2 mg/L, 1.4 +/- 0.5 h, 203.5 +/- 118.4 mgxh/L and 315.1 +/- 151.2 mgxh/L. The half-life of fosfomycin ranged from 2.2 to 2.7 h between compartments. The magnitude of lung tissue penetration, as determined by the ratios of the AUC(0-infinity) for lung to the AUC(0-infinity) for plasma, was 0.63 +/- 0.31 and 0.53 +/- 0.31 for healthy and infected lung, respectively. CONCLUSIONS: We conclude that fosfomycin achieves antimicrobially effective concentrations in infected lung tissue.

Creation of a prevascularized site for cell transplantation in rats.

INTRODUCTION: Transplanted cells, especially islet cells, are likely to become apoptotic due to local hypoxia leading to graft dysfunction. Isolated pancreatic islet cells depend on the diffusion of oxygen from the surrounding tissue; therefore, access to sufficient oxygen supply is beneficial, particularly when microcapsules are used for immunoisolation in xenotransplantation. The aim of this study was to create a prevascularized site for cell transplantation in rats and test its effectiveness with microencapsulated HEK293 cells. METHODS: The combination of implantation of a foam dressing, vacuum-assisted wound closure (foam+VAC) and hyperbaric oxygenation (HBO) was used in 40 Sprague-Dawley rats. Blood flow and vascular endothelial growth factor (VEGF) levels were determined. Sodium cellulose sulphate (SCS)-microencapsulated HEK293 cells were xenotransplanted into the foam dressing in rats pre-treated with HBO, and angiogenesis and apoptosis were assessed. RESULTS: Vessel ingrowth and VEGF levels increased depending on the duration of HBO treatment. The area containing the foam was perfused significantly better in the experimental groups when compared to controls. Only a small amount of apoptosis occurs in SCS-microencapsulated HEK293 cells after xenotransplantation. CONCLUSION: As ischemia-damaged cells are likely to undergo cell death or loose functionality due to hypoxia, therefore leading to graft dysfunction, the combination foam+VAC and HBO might be a promising method to create a prevascularized site to achieve better results in xenogeneic cell transplantation.

Transdiaphragmatic repositioning of the heart in the setting of emergency laparotomy after blunt trauma.

Cardiac luxation after blunt trauma is a rare condition that carries a high mortality rate. We report a case of a left pericardial rupture with partial dislocation of the heart into the left pleural cavity and cardiac strangulation in a polytraumatized patient after a severe motor vehicle accident. This case is of special interest because the patient not only had cardiovascular compromise but was also actually in cardiac arrest and being resuscitated when an emergency repositioning of the heart through the diaphragm in the setting of damage control laparotomy restored circulation. This report stresses the need for a high index of suspicion for accurate early diagnosis of pericardial rupture.

Transthoracic esophagectomy and lobectomy performed in a patient with synchronous lung cancer and combined esophageal cancer and esophageal leiomyosarcoma.

We report a pitfall deriving from the assumption of metastatic disease based upon seemingly identical histology in a pulmonary lesion and in the esophagus. In a 60-year-old patient, cT1 esophageal squamous cell carcinoma was found. One of the two pulmonary nodules was histologically diagnosed as metastasis. When esophageal perforation occurred during palliative therapy, esophagectomy became necessary together with the right lower lobectomy for the removal of the remaining pulmonary lesion. Definitive histology showed pT1N0 cancer of the esophagus, primary esophageal sarcoma and pT4N0 bronchogenic carcinoma. The other pulmonary lesion was re-evaluated and defined as intralobar M1 of bronchogenic carcinoma.

Efficiency of fleece-bound sealing (TachoSil) of air leaks in lung surgery: a prospective randomised trial.

OBJECTIVE: Persistent air leakage following pulmonary resection is a major limiting factor for discharge from hospital. The aim of this study was to evaluate the sealing capacity of TachoSil for the closure of alveolar air leaks following parenchymal resections and to determine its effect on time to chest drain removal and duration of hospitalisation. METHODS: A total of 173 patients undergoing lobectomy or segmentectomy were enrolled in a single-centre, randomised study to compare the efficacy of TachoSil with standard treatment. Alveolar air leaks were evaluated intraoperatively by submersion of the resection site in saline and were graded according to the Macchiarini scale as 0 (no bubbles), 1 (single bubbles), 2 (stream of bubbles), 3 (coalescent bubbles). Patients with grade 1 or 2 air leaks were randomised to TachoSil or standard treatment. Grade 3 patients received standard treatment until the air leak was downgraded to grade 1 or 2 at which point they were randomised. Patients with grade 0 leakage were excluded. The primary efficacy endpoints of the study were postoperative quantification of air leakage on postoperative days 1 and 2. Other efficacy measurements included mean time to chest drain removal and mean time to hospital discharge. RESULTS: The mean intraoperative post-treatment air leakage was significantly lower in the TachoSil group (153.32ml/min, range: 10-450ml/min) compared with the standard treatment group (251.04ml/min, range: 15-970ml/min; P=0.009). The significant difference in air leakage volume observed intraoperatively post-treatment was maintained postoperatively. TachoSil showed a trend towards reduced incidence of postoperative leakage when measured >48h or >7 days after surgery (30.7% vs 38.96% and 24% vs 32.46%, respectively). The mean times to chest drain removal and to hospital discharge were significantly reduced following the use of TachoSil (5.1 days vs 6.3 days, P=0.022 and 6.2 days vs 7.7 days, P=0.01, respectively). CONCLUSIONS: The use of TachoSil following pulmonary resection resulted in a reduction in air leakage compared with standard techniques. This reduction in air leakage resulted in a significant reduction in both the time to chest drain removal and the period of hospitalisation.

The impact of preoperative micronutrient supplementation in lung surgery. A prospective randomized trial of oral supplementation of combined alpha-ketoglutaric acid and 5-hydroxymethylfurfural.

OBJECTIVE: Preoperative micronutrient supplementation in fast-track surgery programs have shown to reduce complications, shorten recovery, and thereby lower costs. In a prospective randomized study, the metabolic effects of a combination of alpha-ketoglutaric acid (alpha-KG) and 5-hydroxymethylfurfural (5-HMF) were evaluated concerning their impact on improvement of exercise capacity and reduction of oxidative stress in lung surgery. METHODS: Thirty-two consecutive patients admitted for lung resection due to NSCLC were randomized to the study protocol. All patients received preoperative nutritional guidelines according to general recommendations. In 16 (study group), a supplementation of 7.2g alpha-KG and 720 mg 5-HMF/day (SANOPAL) was administered from days 1 to 10. Spiroergometric evaluation was carried out at baseline and day 10 after micronutrient supplementation. Blood samples for the determination of oxidative stress, i.e. carbonyl proteins (CPs) and isoprostanes (IPs) were taken on at baseline, in the operating room just before resection treatment, and 25 min after single lung ventilation (SLV). RESULTS: Spiroergometric re-evaluation showed a significant increase of VO2max (p=0.0108) and Watt's (p=0.011) in favor of the study group. Determination of oxidative stress showed a significant reduction of CPs before (p=0.048) and after SLV (p=0.0001) for the study group compared to the control group. The same is true for IPs before (p=0.003) and after SLV (p=0.02). Hospitalization and intensive care unit (ICU) of the study group showed a significant reduction compared to the control group (p=0.03 and p=0.02, respectively). CONCLUSIONS: Simple oral supplementation using a combination of alpha-KG and 5-HMF of preoperative micronutrition may therefore be one further step in a multimodality approach of fast-track surgery programs also in lung surgery.

AIRFIX: the first digital postoperative chest tube airflowmetry--a novel method to quantify air leakage after lung resection.

OBJECTIVE: Prolonged air leak after pulmonary resection is a common complication and a major limiting factor for early discharge from hospital. Currently there is little consensus on its management. The aim of this study was to develop and evaluate a measuring device which allows a simple digital bed-side quantification of air-leaks compatible to standard thoracic drainage systems. PATIENTS AND METHODS: The measuring device (AIRFIX) is based upon a 'mass airflow' sensor with a specially designed software package that is connected to a thoracic suction drainage system. Its efficacy in detecting pulmonary air-leaks was evaluated in a series of 204 patients; all postoperative measurements were done under standardized conditions; the patients were asked to cough, to take a deep breath, to breathe out against the resistance of a flutter valve, to keep breath and to breathe normally. As standard parameters, the leakage per breath or cough (ml/b) as well as the leakage per minute (ml/min) were displayed and recorded on the computer. RESULTS: Air-leaks within a range of 0.25-45 ml/b and 5-900 ml/min were found. Removal of the chest tubes was done when leakage volume on Heimlich valve was less than 1.0 ml/b or 20 ml/min. After drain removal based upon the data from chest tube airflowmetry none of the patients needed re-drainage due to pneumothorax. CONCLUSION: The AIRFIX device for bed-side quantification of air-leaks has proved to be very simple and helpful in diagnosis and management of air-leaks after lung surgery, permitting drain removal without tentative clamping.

The incidence of gastroesophageal reflux after transthoracic esophagocardio-myotomy without fundoplication: a long term follow-up.

OBJECTIVE: Evaluation of the long term results of Heller's myotomy performed over a lateral thoracotomy without additional fundoplication. METHODS: Forty patients (17 males, 23 females; mean age 43.2 years; range: 14-63 years) were operated between 1985 and 2000. Preoperative evaluation included clinical scoring of symptoms, esophagogram, endoscopy, manometry and 24-h ph-metry. At the follow-up investigation, the preoperative evaluation was repeated in all patients, adding a histological workup of the distal esophageal mucosa. The mean duration of follow-up after surgery was 10.3 years, ranging from 3-16 years. RESULTS: The clinical scores improved significantly: Excellent relief from dysphagia was present in 86%, little or no regurgitation was found in 79%, little or no retrosternal spasms were reported by 72% of the patients. Esophagogram showed an overall esophageal dilatation in all patients but no significant obstruction at the esophagogastric junction. Endoscopically, 2.5% had candida-esophagitis, 5% showed signs of a GERD I, 92.5% had a macroscopically insuspect esophageal mucosa. Histologically, 53% showed a mild chronic inflammation. Manometry demonstrated distinct hypomotility of the esophagus in all cases, yet no elevated pressure of the lower sphincter; pH-metry showed moderate reflux in 46%. CONCLUSIONS: Transthoracic cardiomyotomy is a valid method for the treatment of achalasia, but it will not improve the esophageal motility, which slowly deterioriates in these cases. The patient's subjective assessment of the postoperative result was positive in the majority of cases. Although fundoplication was not done in any of these patients, none of them showed signs of clinically relevant reflux.

Occult solitary submucosal jejunal metastasis from esophageal carcinoma.

BACKGROUND: Metastatic tumors of the intestinal tract from extra-abdominal sites are rare. In esophageal cancer, the liver, lung and the bones are the most common sites of metastases. Metastasis to intestines are very rare. CASE PRESENTATION: A 54-year old male was admitted with esophageal squamous cell carcinoma (SCC) associated with dysphagia II-III and weight loss of 20 kg. Preoperative routine staging failed to detect any metastases. A transthoracic esophagectomy and orthotopic gastric pull-up with collar esophago-gastrostomy, associated with 2-field lymphadenectomy was performed. During the digital placement of the naso-jejunal feeding catheter a submucosal jejunal nodule with a diameter of 1 cm, about 40 cm distal to the duodeno-jejunal fold was detected which was completely resected by jejunotomy. Histopathology of jejunal nodule showed metastasis from esophageal squamous cell carcinoma. CONCLUSION: Because of the extensive esophageal lymphatic system, an occult widespread dissemination of the tumor cells into the abdominal cavity is possible. Additional intraoperative evaluation of the small intestine and the complete abdominal cavity should be performed in every operation of esophageal carcinoma to detect possible occult intraabdominal metastases.

Clamshell thoracotomy and open heart massage--A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study.

AIMS: Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. METHODS: We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. RESULTS: The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. CONCLUSION: Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.

Photodynamic therapy enhanced by hyperbaric oxygenation in palliation of malignant pleural mesothelioma: clinical experience.

INTRODUCTION: Surgical debulking followed by radiotherapy/chemotherapy are the standards in the palliative treatment schedule of malignant pleural mesothelioma. The aim of this study was to evaluate the additional effect of intraoperative photodynamic therapy (PDT) under hyperbaric oxygenation (HBO) if compared to decortication alone. PATIENTS AND METHODS: From January 1993 to August 2003, decortication was done in 34 patients (28 males, 6 females; mean age: 65 years) suffering from advanced malignant pleural mesothelioma. Twenty-two patients received additional intraoperative PDT under HBO. The surgery and PDT/HBO was done 48h after photosensitization with a polyhematoporphyrin, 2mg/kg BW using a diode laser delivering red light at 630nm through a microlens. The light dose was calculated for 300J at a distance of 1cm from the tumour surface. RESULTS: At 6-month follow-up the Karnofsky performance status showed no significant difference (P≥0.05) between both groups. CT scans documented focal regrowth of the tumour after 6 months in 10/12 cases of the non-PDT group. However, in the PDT group tumour regrowth was detected in only 9/22 cases at 6-month follow-up. Survival analysis showed a significant advantage for the group with PDT (log-rank test: P=0.0179). CONCLUSION: Although the study includes only a small number of patients, it indicates that additional PDT/HBO represents a safe and technically feasible approach in the palliative setting of advanced malignant mesothelioma of the pleura.