Emergency Thoracic Surgery Research Articles

Biochemical markers in emergency thoracic surgery in penetrating trauma

Biochemical markers in emergency thoracic surgery in penetrating trauma

Emergency thoracic surgery patients have worse risk-adjusted outcomes than non-emergency patients

BackgroundOutcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations. MethodsWe retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005–2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with “emergency status” as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors. ResultsOf 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery. ConclusionPatients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.

Experience of Lung Surgery in the COVID-19 Pandemic

Objective: During the pandemic, elective cases other than those requiring emergency thoracic surgery were postponed. Depending on the magnitude of the impact the pandemic posed on hospitals and clinics, there have been changes in the number and variety of cases of thoracic surgery. The intention behind conducting this study was to share the experiences gained by a thoracic surgery clinic during the pandemic period.Methods: Altogether, 214 patients were included in the study. Patient data that were recorded included those on age, gender, lung pathology, duration of hospital stay, positivity for COVID-19, survival, and causes of death.Results: Of the 214 patients operated on, 12 died during the postoperative period. Eight of these patients died due to their primary disease and one died due to gastrointestinal bleeding, whereas the remaining three patients died due to COVID-19 infection.Conclusions: If opportunities and facilities favorable for the administration of surgical treatment are made available, surgical treatment services can be offered safely to all patients

Emergency Thoracic Surgery in Chest Trauma at the Komfo Anokye Teaching Hospital in Ghana: The Role of Sternotomy and Thoracotomy

Objective: Chest trauma, as blunt or penetrating injury, account for significant amount of all traumatic injuries. They are associated with high mortality of about 75% of all trauma-related deaths, either from direct or indirect consequence of the injury. Nearly 80-85 % of chest trauma is managed conservatively with only about 10-15 % needing emergency surgery.Methodology: A retrospective cohort study of patients presenting with chest trauma and undergoing emergency thoracic surgery at the Komfo Anokye Teaching Hospital from January 2015 to June 2020 was carried out.Results: There were 29 patients, with 82.8% (24) being males. The mean age was 33.8 ± 15.0 years with range of 5-65 years. The leading mechanism of chest trauma was penetrating chest injury, which accounted for 51.7% (15). Eighteen (86%) patients underwent exploratory thoracotomy with 5 (10%) having exploratory sternotomy and the remaining 4% undergoing other procedures. Fourteen (82.1%) patients out of the eighteen who underwent the thoracotomy had a left thoracotomy with four (24.1%) patients having right thoracotomy. The major indication for surgery in acute thoracic trauma was traumatic diaphragmatic rupture (62.1%) followed byimpalement injury (17.2%), traumatic thoracotomy (6.9%), cardiac tamponade (6.9%), massive haemothorax (3.5%), and vascular injury (3.5%). There were no mortality over the 5-year period.Conclusion: The leading indication for emergency thoracic surgery in chest trauma was traumatic diaphragmatic rupture caused mostly by penetrating thoracic injury. Thoracotomy was the major emergency thoracic surgical approach performed.

Acute Mediastinitis Following Esophageal Perforation with Swallowing of Duck Bone: A Case Report

<i>Background</i>: Acute mediastinitis is still associated with a high morbidity and mortality. Mediastinitis secondary to esophageal perforation is a rare but potentially life-threatening condition. <i>Case presentation</i>: This report aims to present an acute mediastinitis case, in a 54-year-old healthy female patient, which originated from an intrathoracic esophageal perforation with swallowing of duck bone that confirmed by computed tomography of the chest. The patient was successfully treated by an emergency left thoracotomy, effective surgical drainage and aggressive debridement of the affected mediastinal compartments, primitive repair of perforated esophagus with intercostal muscle flap, decompressive gastrostomy and jejunostomy for feeding. Post-operatively, the patient was benefited from broad-spectrum antibiotics, intensive care and resuscitation associated with a close follow-up consequence. <i>Results</i>: Mediastinitis was well-controlled. Post interventional computed tomography scan with hydro-soluble contrast ingestion showed no extraluminal leak and good integrity of esophagus. The patient restored normally oral feeding without any complications and was discharged after 24 days of hospitalization without any sequelae. <i>Conclusions</i>: Early diagnosis is critical for expediting the choice of an optimal treatment strategy and plays an important role in improving mortality from acute mediastinitis following perforated esophagus. Besides intensive care and resuscitation, we advocate an emergency thoracic surgery for cases with established mediastinitis following intrathoracic esophageal perforation.

A Dedicated Path to Emergent Thoracic Surgery in COVID-19 Patients: An Italian Institution Protocol

The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic pointed out that the need to ensure emergent surgery in patients positive for infection is no longer hypothetical. Among emergency procedures, thoracic surgical operations are frequent. A standardized surgical pathway is mandatory to achieve effective and safe management of this subset of patients. We briefly present the protocol adopted by our thoracic surgery division.

Preliminary recommendations for lung surgery during COVID-19 epidemic period.

Preliminary recommendations for lung surgery during COVID-19 epidemic period.

Randomised controlled trial to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain (TOPIC): a pilot study to assess feasibility of a large multicentre trial

ObjectivesThoracotomy is considered one of the most painful surgical procedures. The incidence of chronic post-thoracotomy pain (CPTP) is up to 50%. Paravertebral blockade (PVB) may be superior to thoracic epidural...

Blunt cardiac injury due to trauma associated with snowboarding: a case report

BackgroundCardiac trauma is associated with a much higher mortality rate than injuries to other organ systems, even though cardiac trauma is identified in less than 10% of all trauma admissions. Here we report blunt trauma of the left atrium due to snowboarding trauma.Case presentationA 45-year-old Asian man collided with a tree while he was snowboarding and drinking. He lost consciousness temporarily. An air ambulance was requested and he was transported to an advanced critical care center. On arrival, a pericardial effusion was detected by a focused assessment with sonography for trauma. His presenting electrocardiogram revealed normal sinus rhythm and complete right bundle branch block. Laboratory findings included a white blood cell count of 13.5 × 103/μl, serum creatine kinase level of 459 IU/l, and creatine kinase–myocardial band level of 185 IU/l.Enhanced computed tomography showed a large pericardial effusion and bleeding from his left adrenal gland. There were no pelvic fractures. A diagnosis of cardiac tamponade due to blunt cardiac injury and left adrenal injury due to blunt trauma was made. Subsequently, emergency thoracic surgery and transcatheter arterial embolization of his left adrenal artery were performed simultaneously. A laceration of the left atrial appendage in the lateral wall of his left ventricle was detected intraoperatively and repaired. His postoperative course progressed favorably, although a pericardial effusion was still detected on chest computed tomography on hospital day 35. His electrocardiogram showed normal sinus rhythm and the complete right bundle branch block pattern changed to a narrow QRS wave pattern. He was discharged on hospital day 40.ConclusionsThe present case report illustrates two points: (1) severe injuries resulted from snowboarding, and (2) complete right bundle branch block was caused by blunt cardiac injury. The present report showed blunt trauma of the left atrium with complete right bundle branch block as an electrocardiogram change due to snowboarding trauma. To detect cardiac trauma in snowboarding accidents, an examination of an electrocardiogram is required in all patients who might have a bruised chest.

Use of a Combination of Regional and General Anesthesia during Emergency Thoracic Surgery

Objective: to elaborate multimodal anesthetic regimens and to evaluate their efficiency during emergency tho racic surgeries for varying injuries. Subjects and methods. A total of 116 patients emergently admitted to the Republican Research Center for Emergency Medical Care for chest traumatic injuries were examined and divided into 3 groups according to the mode of anesthesia. Results. Perioperative multimodal anesthetic regimens for emergency thoracic surgery, which involved all components of the pathogenesis of pain, were elaborated. Conclusion. The combination of regional and general anesthesia contributes to the smooth course of an intra operative period with minimal hemodynamic stress and it is cost effective in decreasing the use of narcotic anal gesics in the intraoperative period.

Prevention of lung-to-lung aspiration during emergency thoracic surgery: an experimental study.

BackgroundLung separation is essential for an emergency thoracic surgery for massive hemoptysis. When using a double lumen tube (DLT), a commonly adopted lung separation device during thoracic surgery, a water-tight seal of endobronchial cuff is crucial to prevent lung-to-lung aspiration of blood. In this study, we investigated the fluid sealing characteristics of the endobronchial cuff of a DLT and examined the effect of gel lubrication on the fluid leakage beyond the endobronchial cuff of DLT.MethodsAn artificial tracheobronchial tree was intubated with a DLT. In the first phase of the study, the intra-cuff pressure of endobronchial cuff of DLT was set to 25, 50, or 100 cmH2O (n = 7, each), and the non-dependent bronchus was filled with 5 ml of water. Fluid leakage to the dependent bronchus beyond the endobronchial cuff was collected for 6 h. The time until leakage was first detected and the time until 100% leakage occurred were measured. In the second phase, the endobronchial cuff was coated with either saline (group C, n = 10) or lubricant gel (group GEL, n = 10), and the same parameters were measured.ResultsIn the first phase of the study, the times to first leakage and 100% leakage at an intra-cuff pressure of 25 cmH2O were 21.0 (7.0 - 59.0) sec and 3.0 (2.0 - 4.0) min, respectively. Higher intra-cuff (50 and 100 cmH2O) resulted in longer time for the first leakage and 100% leakage, but the duration was not long enough for clinical purpose. In the second phase, all the DLTs in group C showed 100% fluid leakage during the 6-hour period. In contrast, in group GEL, fluid leakage beyond the endobronchial cuff was detected only in 50% of the DLTs and none of the DLT showed 100% fluid leakage during the study. Among the DLTs which exhibited fluid leakage, the time to first leakage was 252.0 (171.0-305.0) min and the leakage volume at the end of the study period was 0.3〔0.0-1.8〕ml.ConclusionsEndobronchial cuff of DLT cannot prevent fluid leakage beyond the endobronchial cuff, but lubricant gel coating on the endobronchial cuff can effectively reduce the lung-to-lung aspiration.

The effectiveness of perioperative oral hygiene in reduction of postoperative respiratory tract infections after thoracic surgery in adults: a systematic review.

Review question/objective The objective of this systematic review is to identify, appraise and synthesise the best available evidence on the effectiveness of systematic perioperative oral hygiene in reduction of post-operative respiratory airway infections in adult patients undergoing elective thoracic surgery. More specifically, the review question is: What is the effectiveness of perioperative systematic oral hygiene compared to patients’ usual oral hygiene in reduction of postoperative upper or lower respiratory tract infections in adult patients undergoing elective thoracic surgery? Inclusion criteria Types of participants This review will consider studies that include patients over the age of 18 years who have been admitted for elective thoracic surgery, regardless of gender, ethnicity, diagnosis severity, comorbidity or previous treatment. The reasons for surgery will include, but not be limited to: elective or acute Coronary Artery By-pass Grafting, (CABG), coronary valve surgery, any type of lung surgery or surgery for oesophageal cancer. Patients undergoing emergency thoracic surgery are outside the scope of the review and will therefore be excluded. Types of interventions and comparators This review will consider studies that evaluate perioperative systematic oral hygiene such as mechanical removal of dental biofilm or plaques and/or systematic use of mouth rinse. This oral hygiene may be performed by patients themselves or by healthcare staff (such as nurses). Tooth brushing interventions: Mechanical plaque control is the removal of microbial plaque and the prevention of accumulation on the teeth and adjacent gingival surface by the use of toothbrush and other mechanical hygiene aids without the use of chemical. Patients following a particular protocol for their tooth brushing for up to seven days before the surgical procedure will be considered for this review. The intervention may specify the frequency of tooth brushing that the patients are instructed to perform each day, the use of a specific method for brushing the teeth or the use of a specific toothpaste for the procedure. TRUNCATED AT 350 WORDS.

Emergency thoracic surgery in elderly patients

ObjectivesEmergency thoracic surgery in the elderly represents an extreme situation for both the surgeon and patient. The lack of an adequate patient history as well as the inability to optimize any co-morbidities, which are the result of the emergent situation, are the cause of increased morbidity and mortality. We evaluated the outcome and prognostic factors for this selected group of patients.DesignRetrospective chart review.SettingAcademic tertiary care referral center.ParticipantsEmergency patients treated at the Department of Thoracic Surgery, University Hospital of Luebeck, Germany.Main outcome measuresCo-morbidities, mortality, risk factors and hospital length of stay.ResultsA total of 124 thoracic procedures were performed on 114 patients. There were 79 men and 36 women (average age 72.5 ±6.4 years, range 65–94). The overall operative mortality was 25.4%. The most frequent indication was thoracic/mediastinal infection, followed by peri- or postoperative thoracic complications. Risk factors for hospital mortality were a high ASA score, pre-existing diabetes mellitus and renal insufficiency.ConclusionsOur study documents a perioperative mortality rate of 25% in patients over 65 who required emergency thoracic surgery. The main indication for a surgical intervention was sepsis with a thoracic/mediastinal focus. Co-morbidities and the resulting perioperative complications were found to have a significant effect on both inpatient length of stay and outcome. Long-term systemic co-morbidities such as diabetes mellitus are difficult to equalize with respect to certain organ dysfunctions and significantly increase mortality.

The Design of an Accidentally Swallowed Partial Denture Resulted in a Major Surgery

Purpose: Foreign body ingestion of a full or a partial denture is common in adults, the size and configuration of such an object compound its impaction and removal, the hazard of the small side plate has long been recognized with suggestions to the dental industry for alternatives and adjustments. A 43-year-old Indian gentleman with no previous medical or surgical history, presented with drooling, and dysphagia with inability to swallow his saliva. His presentation was 9 hours after accidental ingestion of his loose partial 4 teeth denture while he was drinking water, soft tissue x ray showed the foreign body (FB) in the hypo-pharyngeal area with two round metallic hooks Figure-1. Emergency endoscopy under general anesthesia was done, and showed a 4 teeth dental prostheses lodged at the pharyngeal-esophageal junction 4cm below the vocal cord in the cervical esophagus (20 cm from the incisors), the two end metallic hooks deeply impeded in the tissue and only little part of each was seen. Trials to manipulate the FB and remove it were impossible and would create great tension on the hooks for which the procedure was aborted to avoid uncontrolled laceration of the esophagus, emergency thoracic surgery consult was done, and the patient was taken to the operating room immediately. The FB was removed surgically through a left side neck incision, it was reported that the FB was not removable intra-operatively until the fully penetrated hooks were cut from outside the esophagus first. The deign of this prostheses, with sharp fishing hook shaped ends precluded the endoscopic detachment, and resulted in a major surgery. We present this case to the dental industry to avoid these designs and to make the dentures safer in case of accidental ingestion.Figure

Anesthesia for Thoracic Surgery

History of Anesthesia for Thoracic Surgery. Thoracic Anatomy. General Respiratory Physiology and Respiratory Function During Anesthesia. Special Respiratory Physiology of the Lateral Decubitus Position, The Open Chest, And One-Lung Ventilation. Perioperative Cardiopulmonary Evaluation. Perioperative Respiratory Preparation. Monitoring. Choice of Anesthetic Drugs and Techniques. Separation of the Two Lungs (Doubel-Lumen Tube and Bronchial Blocker Intubation). Routine Surgical Considerations that Have Anesthetic Implications. Conventional and Differential Lung Management of One-Lung Ventiliation. High-Frequency and High-Flow Apneic Ventilation During Thoracic Surgery. Anesthetic Considerations (Other Than Management of Ventilation) During and at the End of Thoracic Surgery. Anesthesia for Special Elective Diagnostic Procedures. Anesthesia for Special Elective Therpeutic Procedures. Anesthesia for Esophageal Surgery. Anesthesia for Emergency Thoracic Surgery. Anesthesia for Pediatric Thoracic Surgery. Early Serious Complicatons Specifically Related to Thoracic Surgery. Mechanical Ventiliation and Weaning. Management of Postoperative Pain. Index.