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      The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma

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          Abstract

          OBJECTIVES

          Retained haemothorax and pneumothorax are the most common complications after blunt chest traumas. Lung lacerations derived from fractures of the ribs are usually found in these patients. Video-assisted thoracoscopic surgery (VATS) is usually used as a routine procedure in the treatment of retained pleural collections. The objective of this study was to find out if there is any advantage in adding the procedure for repairing lacerated lungs during VATS.

          METHODS

          Patients who were brought to our hospital with blunt chest trauma were enrolled into this prospective cohort study from January 2004 to December 2011. All enrolled patients had rib fractures with type III lung lacerations diagnosed by CT scans. They sustained retained pleural collections and surgical drainage was indicated. On one group, only evacuation procedure by VATS was performed. On the other group, not only evacuations but also repair of lung injuries were performed. Patients with penetrating injury or blunt injury with massive bleeding, that required emergency thoracotomy, were excluded from the study, in addition to those with cardiovascular or oesophageal injuries.

          RESULTS

          During the study period, 88 patients who underwent thoracoscopy were enrolled. Among them, 43 patients undergoing the simple thoracoscopic evacuation method were stratified into Group 1. The remaining 45 patients who underwent thoracoscopic evacuation combined with resection of lung lacerations were stratified into Group 2. The rates of post-traumatic infection were higher in Group 1. The durations of chest-tube drainage and ventilator usage were shorter in Group 2, as were the lengths of patient intensive care unit stay and hospital stay.

          CONCLUSIONS

          When compared with simple thoracoscopic evacuation methods, repair and resection of the injured lungs combined may result in better clinical outcomes in patients who sustained blunt chest injuries.

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          Most cited references 15

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          Tube thoracostomy. Factors related to complications.

          To determine the complication rate and risk factors associated with tube thoracostomy (TT) in the trauma patient. Retrospective hospital chart review. Level I trauma center. Four hundred twenty-six consecutive patients who underwent TT were initially reviewed; 47 deaths occurred unrelated to TT placement. The remaining 379 patients required 599 tubes and composed the study population. The determination of adverse outcomes related to TT, including thoracic empyema, undrained hemothorax or pneumothorax, improper tube positioning, post-tube removal complications, and direct injuries to the lung. The overall complication rate was 21% per patient. Although complications were not related to the Injury Severity Score, the presence of shock, admission to the intensive care unit, and the need for mechanical ventilation were associated with the increased incidence of complications. There were fewer complications (6%) when the TT was performed by a surgeon compared with TT performed by an emergency physician (13%, P < .0001) or TT performed prior to transfer to our hospital (38%, P < .0001). Tube thoracostomy is associated with significant morbidity. The striking difference in the complication rate between surgeons and other physicians who perform this procedure suggests that additional training may be indicated.
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            Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings.

            This pictorial review discusses multi-detector computed tomography (MDCT) cases of non-vascular traumatic chest injuries, with a brief clinical and epidemiological background of each of the pathology. The purpose of this review is to familiarize the reader with common and rare imaging patterns of chest trauma and substantiate the advantages of MDCT as a screening and comprehensive technique for the evaluation of these patients. Images from a level 1 trauma center were reviewed to illustrate these pathologies. Pulmonary laceration, pulmonary hernia, and their different degrees of severity are illustrated as examples of parenchymal traumatic lesions. Pleural space abnormalities (pneumothorax and hemothorax) and associated complications are shown. Diaphragmatic rupture, fracture of the sternum, sternoclavicular dislocation, fracture of the scapula, rib fracture, and flail chest are shown as manifestations of blunt trauma to the chest wall. Finally, direct and indirect imaging findings of intrathoracic airway rupture and post-traumatic foreign bodies are depicted. The advantage of high quality reconstructions, volume rendered images, and maximal intensity projection for the detection of severe complex traumatic injuries is stressed. The limitations of the initial chest radiography and the benefits of MDCT authenticate this imaging technique as the best modality in the diagnosis of chest trauma.
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              Pulmonary contusions: quantifying the lesions on chest X-ray films and the factors affecting prognosis.

              To quantify pulmonary contusions on chest x-ray film and to evaluate factors correlating with the size of the pulmonary contusions, changes in the first 24 hours, the need for ventilatory assistance, and death. The medical records and chest x-ray films of 103 patients with blunt chest trauma diagnosed as having a pulmonary contusion were reviewed. A pulmonary contusion score was developed (3 = one third of a lung; 9 = an entire lung). In the emergency department, pulmonary contusions were not present in 11, were mild (one ninth to two ninths of a lung) in 15 patients, moderate-severe (three ninths to nine ninths of a lung) in 53 patients, and very severe in 24 patients. Within 24 hours, the pulmonary contusion score increased in 26 patients by 7.9 +/- 5.5 (SD). The 26 patients with an increasing contusion had a higher mortality rate (38% vs. 17%) (p = 0.044) and tended to need ventilatory assistance more frequently (73% vs. 49%) (p = 0.061). The 35 patients with very severe pulmonary contusions (pulmonary contusion score = 10-18) had the lowest PaO2:FIO2 ratio at 24 hours (175 +/- 103 mm Hg), longest hospital length of stay (28 +/- 35 days), and the highest Injury Severity Score (26 +/- 9). The factors correlating highest with a need for ventilatory support (57/103) were the 24 hour or initial PaO2/FIO2 ratio or = 24, Revised Trauma Score or = 26, Revised Trauma Score < or = 6.3, and Glasgow Coma Scale score < or = 11 (p < 0.001). Quantifying and noting changes in the extent of the pulmonary contusions and PaO2/FIO2 ratio during the first 24 hours may be of value in determining the need for ventilatory assistance and predicting outcome.
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                Author and article information

                Journal
                Eur J Cardiothorac Surg
                Eur J Cardiothorac Surg
                ejcts
                ejctsurg
                European Journal of Cardio-Thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery
                Oxford University Press
                1010-7940
                1873-734X
                July 2014
                15 November 2013
                15 November 2013
                : 46
                : 1
                : 107-111
                Affiliations
                [a ]Division of Trauma, Department of Emergency, Veterans General Hospital , Kaohsiung, Taiwan
                [b ]Shih-Chien University , Taipei, Taiwan
                [c ]Division of Trauma, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung, Taiwan
                [d ]Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung, Taiwan
                [e ]Faculty of Medicine, Department of Emergency Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung, Taiwan
                Author notes
                [* ]Corresponding author. Division of Trauma, Department of Surgery, Kaohsiung Medical University Hospital, 100 Tzyou 1st Road, Kaohsiung 807, Taiwan. Tel: +886-73125895, ext.: 7579; fax: +886-73208255; e-mail: hsinglin2002@ 123456yahoo.com.tw (H.-L. Lin).
                [†]

                The first two authors contributed equally to this work.

                Article
                ezt523
                10.1093/ejcts/ezt523
                4057012
                24242850
                © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

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