Duration Of Chest Tube Insertion Research Articles

Small Bowel Obstruction After Neonatal Repair of Congenital Diaphragmatic Hernia-Incidence and Risk-Factors Identified in a Large Longitudinal Cohort-Study.

ObjectiveIn patients with a congenital diaphragmatic hernia (CDH), postoperative small bowel obstruction (SBO) is a life-threatening event. Literature reports an incidence of SBO of 20% and an association with patch repair and ECMO treatment. Adhesions develop due to peritoneal damage and underly various biochemical and cellular processes. This longitudinal cohort study is aimed at identifying the incidence of SBO and the risk factors of surgical, pre-, and postoperative treatment.MethodsWe evaluated all consecutive CDH survivors born between January 2009 and December 2017 participating in our prospective long-term follow-up program with a standardized protocol.ResultsA total of 337 patients were included, with a median follow-up of 4 years. SBO with various underlying causes was observed in 38 patients (11.3%) and significantly more often after open surgery (OS). The majority of SBOs required surgical intervention (92%). Adhesive SBO (ASBO) was detected as the leading cause in 17 of 28 patients, in whom surgical reports were available. Duration of chest tube insertion [odds ratio (OR) 1.22; 95% CI 1.01–1.46, p = 0.04] was identified as an independent predictor for ASBO in multivariate analysis. Beyond the cut-off value of 16 days, the incidence of serous effusion and chylothorax was higher in patients with ASBO (ASBO/non-SBO: 2/10 vs. 3/139 serous effusion, p = 0.04; 2/10 vs. 13/139 chylothorax, p = 0.27). Type of diaphragmatic reconstruction, abdominal wall closure, or ECMO treatment showed no significant association with ASBO. A protective effect of one or more re-operations has been detected (RR 0.16; 95% CI 0.02–1.17; p = 0.049).ConclusionThoracoscopic CDH repair significantly lowers the risk of SBO; however, not every patient is suitable for this approach. GoreTex®-patches do not seem to affect the development of ASBO, while median laparotomy might be more favorable than a subcostal incision. Neonates produce more proinflammatory cytokines and have a reduced anti-inflammatory capacity, which may contribute to the higher incidence of ASBO in patients with a longer duration of chest tube insertion, serous effusion, chylothorax, and to the protective effect of re-operations. In the future, novel therapeutic strategies based on a better understanding of the biochemical and cellular processes involved in the pathophysiology of adhesion formation might contribute to a reduction of peritoneal adhesions and their associated morbidity and mortality.

Safety and Efficacy of Indomethacin for Reducing Chest Tube Duration After Coronary Artery Bypass Grafting Surgery.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) contain a boxed warning for use in coronary artery bypass graft (CABG) surgery due to increased risk of thrombotic events, but recent research has challenged the assumption that these risks are a class effect. One anecdotal indication for NSAIDs in CABG is reducing chest tube output. Objective: The primary objective of this retrospective study was to determine whether indomethacin was associated with reduced duration of chest tube insertion after CABG surgery, defined as total chest tube duration in controls versus duration of chest tube insertion after the first dose of indomethacin in the treatment group. Secondary objectives were comparisons of daily reductions in chest tube output volume, length of stay, and safety between groups. Methods: In this retrospective, single-center case-control review, adult patients who received indomethacin after CABG were matched 1:1 to control patients based on age, sex, concomitant valve surgery, and, when possible, diabetes status. Results: Thirty-two patients were included. The mean age was 56 years and 75% were men. The primary outcome measure was 94 hours among control patients and 82.8 hours among indomethacin patients (P = 0.041). Insignificant mean reductions in daily chest tube output were observed prior to and after indomethacin initiation (38.7 vs 87.7 mL/day, P > 0.05). Conclusion: In this small, single-center study, indomethacin appeared safe and possibly effective for reducing chest tube duration after CABG surgery. Future large, prospective, randomized studies should be conducted to confirm the results.

Efficacy and safety of thoracoscopic talc pleurodesis in the treatment of malignant pleural effusion

ObjectiveTo evaluate the efficacy and safety of thoracoscopic talc pleurodesis in the management of malignant pleural effusion (MPE).BackgroundMPE is a common complication of advanced malignancy. Pleurodesis is a well-recognized treatment for the management of MPE. Talc is considered the most effective sclerosing agents used to produce pleurodesis.Patients and methodsThis is a retrospective chart review of all patients with MPE who underwent thoracoscopic talc pleurodesis for the management of MPE from April 2020 to December 2021.ResultsA total of 24 patients with MPE who underwent thoracoscopic talc pleurodesis for the management of MPE were included in the study. The mean age was 63 ± 8.35 years, and included 12 (50%) males and 12 (50%) females. Overall, low-grade fever was seen in four (16.67%) patients, pleuritic chest pain in three (12.5%) patients, and no complication in 17 (70.83%) patients. No recurrence of pleural effusion happened in 21 (87.5%) patients, recurrence in the form of localized effusion that did not need medical interference happened in two (8.33%), and recurrence in the form of diffuse effusion that needed medical interference happened in one (4.17%) patient. Operative time was 43.75 ± 6.63 min, duration of chest tube insertion was 3.25 ± 0.44 days, and hospital stay was 6 ± 0.72 days.ConclusionsThoracoscopic talc pleurodesis for the treatment of MPE is a feasible and effective treatment with short operative time, is a minimally invasive procedure, and has few adverse effects, making it a safe and effective option for managing patients with MPE.

Congenital Pulmonary Airway Malformation in Children: Advantages of an Additional Trocar in the Lower Thorax for Pulmonary Lobectomy.

Aim: To present the use of an additional trocar (AT) in the lower thorax during thoracoscopic pulmonary lobectomy (TPL) in children with congenital pulmonary airway malformation.Methods: For a lower lobe TPL (LL), an AT is inserted in the 10th intercostal space (IS) in the posterior axillary line after trocars for a 5-mm 30° scope, and the surgeon's left and right hands are inserted conventionally in the 6th, 4th, and 8th IS in the anterior axillary line, respectively. For an upper lobe TPL (UL), the AT is inserted in the 9th IS, and trocars are inserted in the 5th, 3rd, and 7th IS, respectively. By switching between trocars (6th↔8th for the scope, 4th↔6th for the left hand, and 8th↔10th for the right hand during LL and 5th↔7th, 3rd↔5th, and 7th↔9th during UL, respectively), vital anatomic landmarks (pulmonary veins, bronchi, and feeding arteries) can be viewed posteriorly. The value of AT was assessed from blood loss, operative time, duration of chest tube insertion, requirement for post-operative analgesia, and incidence of perioperative complications.Results: On comparing AT+ (n = 28) and AT– (n = 27), mean intraoperative blood loss (5.6 vs. 13.0 ml), operative time (3.9 vs. 5.1 h), and duration of chest tube insertion (2.2 vs. 3.4 days) were significantly decreased with AT (p < 0.05, respectively). Differences in post-operative analgesia were not significant. There were three complications requiring conversion to open/mini-thoracotomy: AT– (n = 2; bleeding), AT+: (n = 1; erroneous stapling).Conclusions: An AT and switching facilitated posterior dissection during TPL in children with congenital pulmonary airway malformation enhancing safety and efficiency.

Empyema Thoracis in Children: Can Pleural Fluid Culture Positivity Affect the Outcome?

Background: Empyema thoracis in children continues to be a major problem with significant morbidity in developing countries despite recent advances in management. This study was aimed to evaluate the clinico-etiology and compare the outcomes of sterile and culture-positive pleural fluid empyema thoracis in North Indian children. Patients and Methods: A total of sixty admitted children satisfying the inclusion criteria were enrolled in the study from October 2018 to September 2020 with parental consent. Bacteriological etiology was confirmed by pleural fluid culture. Disease outcome was evaluated by duration of chest tube insertion, hospital stay, mortality, and successfully discharged patients. The outcomes were compared between patients with sterile and positive pleural fluid culture. Results: The average age of the patients was 4.72 ± 3.52 years with male preponderance (male/female ratio: 1.3:1). Forty-five percent of the patients were between 1 and 5 years. The most common predisposing factor was pneumonia. Fever and cough were the most common manifestations. Pleural fluid culture was positive in 28.3%, with Staphylococcus aureus being the most common organism isolated. Intercostal drainage (ICD) tube was used in 93.3% of the patients and was successful in 80%. The average period of ICD tube placement was 9 ± 4.18 days while hospital stay was 21 ± 9.12 days. Mortality was 1.7%. No statistical significant difference was found in outcomes between patients with sterile and culture-positive pleural fluid. Conclusions: S. aureus was the most common cause of empyema thoracis in this study. The high proportion of culture-negative specimens indicates that pleural fluid culture is not a satisfactory diagnostic tool to find the causative organism.

The application of virtual segmentectomy based on three-dimensional computed tomography and angiography in thoracoscopic segmentectomy for children and infants.

The purpose of this retrospective study was to evaluate the efficacy of anatomic thoracoscopic pulmonary segmentectomy performed based on three-dimensional computed tomography bronchography and angiography (3D-CTBA) in children and infants. Totally, 22 patients received thoracoscopic segmentectomy from October 2019 to February 2020. The procedures were performed virtual segmentectomy based on 3D-CTBA. The preoperative planning depended on the 3D-CTBA result. All of the 22 cases ( 1 left S1, 1 right S3, 1 left S1 + 2, 1 left S1 + 2 + 3, 1 left S4 + 5, 1 right S6, 1 right S10, 1 left S10, 2 right S9 + 10, 3 left S9 + 10, 1 right S7 + 8 + 9 + 10, 8 left S7 + 8 + 9 + 10) were received thoracoscopic segmentectomy successfully. The mean procedure length was 76.6 ± 17.2min, and the intraoperative blood loss was 16.5 ± 2.8ml. The mean duration of chest tube insertion was 3.2 ± 0.7 days, and the mean hospital stay was 8.2 ± 2.8 days. Postoperative complications included infection (n = 1), atelectasis (n = 1), hydropneumothorax (n = 1) and pneumothorax (n = 1). No recurrence or mortality was observed during the short-term follow-up period of 3months. Based on the 3D-CTBA technique, the specific pulmonary segments invaded by the lesions and the relationship between the corresponding pulmonary vessels and bronchi can be acknowledged before the operation, which is of positive significance for the resection of complex pulmonary segments and good preoperative surgical planning. It's worth popularizing in the pediatric population.

Management of the Pediatric Spontaneous Pneumothorax: The Role of Video-Assisted Thoracoscopic Surgery.

Purpose: Treatment of pneumothorax involves conservative treatment and surgery. The aim of this study was to assess the best approach of initial treatment and long-term outcomes of video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax in pediatric patients. Patients and Methods: From January 2009 until June 2019, 36 patients younger than the age of 18 who were treated for spontaneous pneumothorax were included into retrospective study. Patients were divided into 2 groups, non-VATS and VATS, depending on the way they were treated. The groups were compared regarding demographic and clinical data and outcomes of treatment (the length of hospitalization, the frequency of postoperative complications, and reoperations). Results: Out of 36 patients, there were 24 boys and 12 girls with median age of 16.5 years. Median duration of hospitalization was 8 days. Eight patients were treated by observation and 28 by chest tube insertion. In 14 patients with spontaneous pneumothorax, VATS was performed [indications were persistent air leak in 8 (57%) and recurrent pneumothorax in 6 (43%) children]. Patients who underwent surgery had significantly higher length of hospitalization (P < .001) and lower rate of recurrences (P = .003) than those who did not. In 12 (86%) patients, blebs were found intraoperative, and in all of them, pleurodesis was performed. Duration of chest tube insertion was significantly longer in patients who experienced recurrent pneumothorax (P < .001). Conclusions: VATS is successful, efficient, and safe method of treatment for spontaneous pneumothorax, due to its significantly lower rate of recurrence in comparison with chest tube insertion.

Does fissure status affect the outcome of thoracoscopic pulmonary lobectomy?

We studied fissure status and devices used to divide lung parenchyma during thoracoscopic pulmonary lobectomy (TPL). 52 consecutive TPL indicated for congenital pulmonary airway malformation or interlobar pulmonary sequestration performed between 2009 and 2019 were reviewed prospectively to compare patients with absent fissure and no visible interlobar pulmonary artery (IPA) treated by stapling (group A; n = 10), incomplete fissure with partially visible IPA treated with an Enseal® or LigaSure™ device (group I; n = 17), and complete fissure with fully visible IPA treated by electrocautery (group C; n = 25). Patient demographics were similar. Mean age at TPL was 2.82years (range 0.03-9.81). Mean duration of follow-up was 4.77years (range 0.33-10.19). Operative time and duration of chest tube insertion were similar (p = NS). Intraoperative blood loss was significantly lower in group C compared with group I (p = 0.028). Complications were minor bronchial artery hemorrhage during anterior-to-posterior bronchial dissection (group A: n = 1; group I: n = 1), problematic single lung ventilation (group I: n = 1), and persistent postoperative air leak (group I: n = 1). While fissure status does not appear to affect the outcome of TPL in children, the choice of device for dividing lung parenchyma relies specifically on fissure status.

Effect of different therapeutic strategies on the clinical outcome of asymptomatic intralobar pulmonary sequestration.

Pulmonary sequestration is a rare congenital pulmonary malformation. The aim of this study was to explore the effect of different therapeutic strategies on the clinical outcome of asymptomatic intralobar pulmonary sequestration. We retrospectively reviewed the clinical data of 37 patients diagnosed with intralobar sequestration. All the patients were asymptomatic. Seventeen patients underwent video-assisted thoracoscopic surgery (VATS) once diagnosed and 20 patients chose to undergo observation. Of these 20 patients, 16 patients developed symptoms during the observation period and also underwent VATS; 4 patients never showed symptoms and did not have surgery. The 33 patients who had VATS were divided into 2 groups: group 1, patients who underwent VATS once diagnosed; group 2, patients who underwent VATS once symptoms appeared. Postoperative data and respiratory function data were compared between the 2 groups. Twenty of the patients were men and 17 were women (mean age 37.05 ± 7.89 years). Results of a comparative analysis of the 2 groups indicated that patients in group 1 had better values for median estimated blood loss, median duration of chest tube insertion, postoperative hospital stay and postoperative hospital stay than those in group 2. Postoperative complications were reported in 1 patient in group 1 and in 3 patients in group 2. Meanwhile, the loss of lung function between group 1 and group 2 was statistically significant, which also suggested that patients benefited from surgery once diagnosed. For asymptomatic intralobar sequestration, VATS could be effective and safe. The surgical intervention should be performed once the condition is diagnosed to avoid manifestations occurring and to preserve patients' quality of life.

Determination of the intersegmental plane using the slip-knot method.

Visualization of intersegmental planes in the lung is desirable for precise anatomical lung segmentectomy. We developed the slip-knot method for creating inflation-deflation lines. This study aimed to assess relevant data for thoracoscopic segmentectomy performed using this method. In the slip-knot method, the objective segmental bronchus is looped with a monofilament thread. One end of the thread is then pulled during temporary bilateral ventilation, causing the knot to slip toward the bronchus. Thereafter, bronchial ligation is tightened to block the outflow of segmental air, ensuring that the segment remains expanded while the other reserved segments collapse on resumption of unilateral ventilation. Data from 221 patients who underwent thoracoscopic pulmonary segmentectomy between 2010 and 2016 were analyzed. A total of 147 patients (67%) were indicated for the slip-knot method, and 74 cases (33%) were non-adaptive cases. Ninety six percent of 147 cases were well adapted to the slip-knot method, which allowed us to obtain good inflation-deflation line images to determine the intersegmental plane. The mean operative time was 171±51 min (range, 71-367 min). The mean duration of chest tube insertion was 1.5±1.2 days (range, 1-7 days). Three cases (2.0%) had prolonged air-leakage and one (0.7%) case had readmission for late air-leakage. Our method enables determination of anatomical intersegmental planes using only one monofilament thread, thus facilitating thoracoscopic pulmonary anatomical segmentectomy.

Hemodynamic Profile of Acute Kidney Injury Following the Fontan Procedure: Impact of Renal Perfusion Pressure.

Acute kidney injury (AKI) is common following cardiopulmonary bypass. Fontan completion may result in systemic venous hypertension and low cardiac output, reducing renal perfusion pressure (RPP) and further increasing the risk of AKI. We investigated the incidence and risk factors for post-Fontan AKI. Single-center retrospective study of children undergoing Fontan completion from 2005 to 2012. Demographic and hemodynamic variables were assessed for association with AKI. Subgroup analysis was performed on patients with high-grade AKI (creatinine increase of ≥2.0 × baseline). Vital sign data were collected hourly for the first postoperative day. A total of 186 patients underwent Fontan at 3.1 (2.5-3.8) years of age and 13.5 kg (12.2-15.1). Acute kidney injury occurred in 97 (52%) patients, with high-grade AKI in 52 (28%). Univariate analysis identified reduced RPP in patients with AKI compared to those without AKI, 50 (45-56) mm Hg versus 58 (54-61) mm Hg ( P < .0001), due to lower mean arterial blood pressure, 63 (60-69) versus 70 (66-73) mm Hg ( P < .0001), and higher central venous pressure, 14 (12-16) versus 13 (11-14) mm Hg, ( p < .0001). Multivariable logistic regression and classification tree analyses further identified elements of RPP as significant predictors of AKI, especially high-grade AKI. Postoperative intubation was linked to AKI development. Patients with AKI had decreased postoperative urine output with increased colloid requirements, duration of chest tube insertion, and hospital length of stay. Acute kidney injury occurs frequently following the Fontan procedure. Associated factors include reduced RPP, high colloid requirements, and postoperative intubation. Targeted hemodynamic interventions may serve to reduce the incidence of post-Fontan AKI.

Posterior approach to thoracoscopic pulmonary segmentectomy of the dorsal basal segment: A single-institute retrospective review

ObjectiveAnatomic resection of the dorsal area of the basal segment of the lower lobe is difficult because of the deep location of vessels and bronchi in the parenchyma. This study aimed to describe a novel technique for port-access thoracoscopic segmentectomy of the dorsal (S10) and lateral dorsal segments (S9+10). MethodsThis retrospective study analyzed 20 patients who underwent S10 and S9+10 thoracoscopic segmentectomy via a posterior approach between January 2004 and March 2016. In this approach, the lung parenchyma between S6 and S10 was divided along V6b,c from the dorsal side of the lower lobe, which exposed the targeted bronchus (B10, B9+10) and artery (A10, A9+10) and enabled anatomic S10 and S9+10 segmentectomy. ResultsOf the 20 patients, 15 had lung cancer, 3 had metastases, and 2 had benign nodules. The number of segmentectomies of the right S10, right S9+10, left S10, and left S9+10 was 5, 5, 1, and 9, respectively. Median operative time was 165 minutes (range, 107-276 minutes). The median duration of chest tube insertion was 1 day (range, 1-2 days). One patient had atelectasis. Median hospital stay was 6 days (range, 3-11 postoperative days). No recurrence or mortality was observed during the median follow-up period of 46 months. ConclusionsThe posterior approach for port-access thoracoscopic segmentectomy at S10 or S9+10 is technically challenging, but in our hands it has been feasible. It exposes the targeted bronchus (B10, B9+10) and artery (A10, A9+10) and enables anatomic S10 and S9+10 segmentectomy while avoiding inessential parenchymal splitting from the major fissure.

Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience

Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery. We defined "unexpected intraoperative bleeding" as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels. Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3%) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n=13) and vein (n=3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5days, average, p=0.20) and postoperative hospital stay (12.7 vs. 11.0days, average, p=0.08) were not significantly different. The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.

Factors affecting postoperative respiratory tract function in type-C esophageal atresia. Thoracoscopic versus open repair.

We assessed the outcome of 72 cases of type-C esophageal atresia (EAc) treated by open (OR) or thoracoscopic (TR) repair from 2000 to 2013. During OR, direct lung retraction (DLR) is required but during TR, CO2 insufflation causes lung collapse so DLR is unnecessary. Patient demographics, operative time, respiratory tract impact (RTI: incidence of atelectasis, timing of extubation, need for reintubation, and duration of chest tube insertion), narcotic usage, commencement of oral feeding, and length of hospitalization (LOH) were compared. Seven long-gap cases were excluded, leaving 65 EAc subjects (TR = 25, OR = 40). Patient demographics, operative time, and duration of chest tube insertion were similar. No TR case required DLR. Significant differences were found in TR for narcotic usage (1.6 vs. 3.1 days), commencement of feeding (7.8 vs. 10.5 days), incidence of atelectasis (8 vs. 30 %), initial extubation (2.8 vs. 5.6 days), and LOH (33 vs. 46 days), (all p < 0.05, respectively). Postoperative tracheal tube blockage caused by excessive secretions (4 vs. 10 %) and reintubation (4 vs. 17.5 %) were less in TR but not significant. There were three anastomotic leakages in TR, one in OR. TR is less traumatic than OR because DLR is unnecessary, resulting in lower RTI and smooth recovery.

How early should VATS be performed for retained haemothorax in blunt chest trauma?

BackgroundBlunt chest injury is not uncommon in trauma patients. Haemothorax and pneumothorax may occur in these patients, and some of them will develop retained pleural collections. Video-assisted thoracoscopic surgery (VATS) has become an appropriate method for treating these complications, but the optimal timing for performing the surgery and its effects on outcome are not clearly understood. Materials and methodsIn this study, a total of 136 patients who received VATS for the management of retained haemothorax from January 2003 to December 2011 were retrospectively enrolled. All patients had blunt chest injuries and 90% had associated injuries in more than two sites. The time from trauma to operation was recorded and the patients were divided into three groups: 2–3 days (Group 1), 4–6 days (Group 2), and 7 or more days (Group 3). Clinical outcomes such as the length of stay (LOS) at the hospital and intensive care unit (ICU), and duration of ventilator and chest tube use were all recorded and compared between groups. ResultsThe mean duration from trauma to operation was 5.9 days. All demographic characteristics showed no statistical differences between groups. Compared with other groups, Group 3 had higher rates of positive microbial cultures in pleural collections and sputum, longer duration of chest tube insertion and ventilator use. Lengths of hospital and ICU stay in Groups 1 and 2 showed no statistical difference, but were longer in Group 3. The frequency of repeated VATS was lower in Group 1 but without statistically significant difference. DiscussionThis study indicated that an early VATS intervention would decrease chest infection. It also reduced the duration of ventilator dependency. The clinical outcomes were significantly better for patients receiving VATS within 3 days under intensive care. In this study, we suggested that VATS might be delayed by associated injuries, but should not exceed 6 days after trauma.

Empyema thoracis in children: A short term outcome study

This study prospectively evaluates clinical course of pyogenic empyema thoracis in 25 children (2 mo to 12 y) treated with injectable antibiotics and chest tube drainage, and followed for 6 weeks. The median (range) age at presentation was 3 y (4 mo to 11 y). The pleural fluid culture was positive in 24% of patients. Staphylococcus aureus was the most commonly isolated organism. The median (range) duration of injectable antibiotics was 14(14-52) d; median duration of total antibiotics (injectable and oral) was 4 weeks. The median (range) duration of chest tube insertion and hospital stay was 8(5-45) and 14(14-56) days, respectively. All patients were discharged without any surgical intervention besides chest tube drainage. At discharge, pleural thickening was present in 84% and crowding of ribs was seen in 60% of the subjects on radiological examination. All these patients were asymptomatic at discharge. Chest deformity was present in 20% of the patients at 6-weeks follow up. Antibiotics and chest tube drainage is an effective method of treating pyogenic empyema thoracis in children in resource-poor settings.

Factors Affecting Pneumonia Occurring to Patients with Multiple Rib Fractures

BackgroundRib fractures are the most common type of thoracic trauma and cause other complications. We explored the risk factors for pneumonia in patients with multiple rib fractures.Materials and MethodsFour hundred and eighteen patients who visited our hospital with multiple rib fractures between January 2002 and December 2008 were retrospectively reviewed. Chest X-rays and chest computed tomography were used to identify injury severity. Patients with only a single rib fracture or who were transferred to another hospital within 2 days were excluded.ResultsThere were 327 male patients (78%), and the median age was 53 years. The etiologies of the patients' trauma included traffic accidents in 164 cases (39%), falls in 78 cases (19%), slipping and falling in 90 (22%), pedestrian accidents in 30 (7%), industrial accidents in 41 (10%), and assault in 15 (4%). The median number of rib fractures was 4.8. Pulmonary complications including flail chest (2.3%), lung contusion (22%), hemothorax (62%), pneumothorax (31%), and hemopneumothorax (20%) occurred. Chest tubes were inserted into the thoracic cavity in 216 cases (52%), and the median duration of chest tube insertion was 10.26 days. The Injury Severity Score (ISS) and rib score had a median of 15.27 and 6.9, respectively. Pneumonia occurred in 18 cases (4.3%). Of the total cases, 33% of the cases were managed in the intensive care unit (ICU), and the median duration of stay in the ICU was 7.74 days. Antibiotics were administered in 399 patients (95%) for a median of 10.53 days. Antibiotics were used for more than 6 days in 284 patients (68%). The factors affecting pneumonia in patients with multiple rib fractures in multivariate analysis included age (p=0.004), ISS (p<0.001), and rib score (p=0.038). The use of antibiotics was not associated with the occurrence of pneumonia (p=0.28). In-hospital mortality was 5.3% (n=22).ConclusionThe factors affecting risk of pneumonia in patients with multiple rib fractures included age (p=0.004), ISS (p<0.001), and rib score (p=0.038). Elderly patients with multiple traumas have a high risk of pneumonia and should be treated accordingly.

Endoscopic resection of intrathoracic tumors: experience with and long-term results for 26 patients

Thoracoscopy may be used in place of thoracotomy to resect intrathoracic neoplasms such as paraspinal neurogenic tumors. Although these tumors are rare, they account for the majority of tumors arising in the posterior mediastinum. A database was maintained of all patients undergoing thoracoscopic surgery for tumors. The authors analyzed the presenting symptoms, pathological diagnoses, and outcomes of 26 patients (7 males and 19 females, mean age 37.2 years) who were treated for intrathoracic tumors via thoracoscopy between January 1995 and May 2009. Fourteen patients were diagnosed incidentally (54%). Five patients (19%) presented with dyspnea or shortness of breath, 4 (15%) with pain, 1 (4%) with pneumonia, 1 (4%) with hoarseness, and 1 (4%) with Horner syndrome. Pathology demonstrated schwannomas in 20 patients (77%). Other diagnoses included ganglioneurofibroma, paraganglioma, epithelioid angiosarcoma, benign hemangioma, benign granular cell tumor, and infectious granuloma. One patient required conversion to open thoracotomy due to pleural scarring to the tumor. One underwent initial laminectomy due to intraspinal extension of the tumor. Gross-total resection was obtained in 25 cases (96%). The remaining patient underwent biopsy followed by radiation therapy. The mean surgical time was 2.5 hours, and the mean blood loss was 243 ml. The mean duration of chest tube insertion was 1.3 days, and the mean length of hospital stay was 3.0 days. Cases that were treated in the second half of the cohort were more often diagnosed incidentally, performed in less time, and had less blood loss than those in the first half of the cohort. There was 1 case of permanent treatment-related morbidity (mild Horner syndrome). All previously employed patients were able to return to work (mean clinical follow-up 43 months). There were no recurrences (mean imaging follow-up 54 months). Endoscopic transthoracic approaches can reduce approach-related soft-tissue morbidity and facilitate recovery by preserving the normal tissues of the chest wall, by avoiding rib retraction and muscle transection, and by reducing postoperative pain. This less invasive approach thus shortens hospital stay and recovery time.

Clinical Analysis of Video Assisted Thoracic Surgery for the Treatment of Thoracic Empyema

Sang-Gi Oh, M.D.*, Sang-Yun Song, M.D.**, Chi-Hyeong Yun, M.D.*, Kook-Ju Na, M.D.*, Kang-Eun Kong, B.A.**, Song-Ran Park, B.A.**, Sang-Hyung Kim, M.D.*. Korean J Thorac Cardiovasc Surg 2010;43:139-43. https://doi.org/10.5090/kjtcs.2010.43.2.139

Lung Cancer Surgery in Patients With Liver Cirrhosis

Few reports have described surgery for lung cancer in patients with liver cirrhosis. The objective of this study was to clarify the efficacy of surgical treatment and evaluate its postoperative outcome. We retrospectively reviewed the medical charts of 17 patients between 1985 and 2005 who were found to have nonsmall cell lung cancer (NSCLC) with liver cirrhosis. The grading of the severity of liver cirrhosis was made according to the Child-Pugh classification. Four patients were classified as Child-Pugh class A, whereas another 13 patients were classified as Child-Pugh class B. Of these 17 patients, 11 underwent lobectomies, 3 underwent pneumonectomies, and 3 underwent wedge resections. The only patient who experienced hospital death (5.9%) was a male patient with Child-Pugh class B cirrhosis. There were five respiratory-associated postoperative complications including pneumonia, bleeding from the staple line, and prolonged air leak. The morbidity rate was 29.5%. Median duration of chest tube insertion was 6.8 days, and mean volume of pleural effusion was 1,015.0 mL at 3 days total postoperatively. A total of 9 deaths occurred during follow-up (3 from cancer, 4 from hepatic failure, 1 from cardiac causes, and 1 unknown). The overall survival was 87.8%, 57.0%, and 45.6% at 1, 3, and 5 years, respectively. None of the patients experienced morbidity or mortality in Child-Pugh class A, but class B had 30.8% morbidity and 7.6% mortality. Surgical treatment may be an acceptable and valuable approach for NSCLC patients who also have low severity liver cirrhosis.