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PubMed2001

Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study.

HYPOTHESIS: It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality. DESIGN: A retrospective case series. SETTING: Five urban trauma centers. STUDY SELECTION: Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy). DATA EXTRACTION: Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated. MAIN OUTCOME MEASURE: Death. RESULTS: One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001). CONCLUSIONS: The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.

Adult↗
PubMed1996

Disadvantages of muscle-sparing thoracotomy in patients with lung cancer.

At our institute patients with lung cancer had traditionally undergone lobectomy with mediastinal lymph node dissection using a standard posterolateral approach. The considerable morbidity associated with the standard posterolateral thoracotomy led us to investigate an alternative muscle-sparing approach. A prospective, randomized study of 30 patients with primary lung cancer (stage I or II) was performed to compare the following: operative field size, number of dissected lymph nodes, surgery time, postoperative pain, shoulder range of motion, and pulmonary function test results between patients who underwent either standard thoracotomy (SP group, n = 15) or the muscle-sparing thoracotomy (MS group, n = 15). The procedure should provide enough operative field size to access to mediastinum. Compared with the standard posterior thoracotomy, the muscle-sparing thoracotomy supplied a smaller operative field (218 +/- 31 versus 165 +/- 41 cm2) and required more surgery time (87 +/- 13 minutes) than the standard posterior thoracotomy (66 +/- 12 minutes). There were no significant differences in the number of dissected mediastinal lymph nodes. During the early postoperative days, pain and restriction of shoulder flexion were significantly less in the MS group than in the SP group. There were no significant differences in pulmonary function between the two groups. In terms of the operative field there is a marked disadvantage with the muscle-sparing incision compared with standard thoracotomy. The operative field is significantly smaller than with a standard thoracotomy, requiring more time to dissect the mediastinum; however, the pain is less and shoulder range of motion is superior to what is seen after standard thoracotomy during the early postoperative period. We conclude that there is no overall advantage to using the muscle-sparing incision in patients with lung cancer.

Female↗
PubMed2004

The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis.

BACKGROUND: It is assumed that a right anterolateral thoracotomy for correction of simple congenital cardiac defects (ie, atrial septal defect) achieves more favorable cosmetic results than a standard median sternotomy. METHODS: Ninety-five patients, 72 with right anterolateral thoracotomy and 23 with median sternotomy, who had corrective transatrial operations when they were younger than 12 years of age were contacted by questionnaire. The mean follow-up time was 23.1 years. Of these, 61 patients (46 thoracotomy and 15 sternotomy) were investigated clinically. Volume differences of the breasts were measured by 3-dimensional surface scanning. By using photographs of the upper chest, breast symmetry was described by an index. The degree of scoliosis was measured by clinical examination. RESULTS: According to the questionnaire analysis, 76% (thoracotomy group) versus 39% (sternotomy group) thought that the cosmetic result was excellent (P =.008). Breast volume measurement showed a volume difference greater than 20% (left side larger than right) in 55% (thoracotomy) versus 0% (sternotomy). With our index, asymmetry in the lower part of the right breast occurred in 61% (thoracotomy) versus 0% (sternotomy; P <.001). A total of 6.6% of the patients had scoliosis, without any differences between groups. CONCLUSIONS: Because our long-term follow-up in prepubescent female patients after right anterolateral thoracotomy revealed significantly impaired unilateral breast development, we propose to abandon right anterolateral thoracotomy in this subgroup of patients, although the subjective satisfaction with the cosmetic result was high. To avoid potential damage of future breast tissue, other surgical approaches, such as right posterior thoracotomy, should be considered. According to the orthopedic investigation, the surgical approach does not cause a higher rate of scoliosis.

Adult↗
PubMed1996

Comparison of long-term outcomes of patients treated with nonthoracotomy and thoracotomy implantable defibrillators.

In 193 consecutive patients treated with implantable defibrillators at our institution, thoracotomy approaches were used in 87 patients and nonthoracotomy approaches in 106 patients. Long-term outcomes of the 2 groups were compared by the intention-to-treat analysis. Surgical mortality (30-day mortality) rates were 5.7% in the thoracotomy group and 0% in the nonthoracotomy group. Six of 106 patients who underwent nonthoracotomy implantation had a high defibrillation threshold and did not receive nonthoracotomy defibrillators. The duration of follow-up was 52 +/- 31 months in the thoracotomy group, and 23 +/- 15 months in nonthoracotomy group. Actuarial survival rates at 6 and 24 months were, respectively, 90% and 81% in nonthoracotomy patients and 89% and 80% in thoracotomy patients (p = NS). In patients with left ventricular ejection fraction <30%, surgical mortality was 0% by the nonthoracotomy and 10% by the thoracotomy approach. Despite the 10% difference in 30-day mortality, survival rates at 6 months were 85% in nonthoracotomy patients and 81% in thoracotomy patients. At 24 months they were 73% in nonthoracotomy patients and 74% in thoracotomy patients. Thus, this nonrandomized study suggests that while short-term survival is better in nonthoracotomy patients than thoracotomy patients, the difference in survival diminishes quickly during the first few months and disappears by 6 months. The results were similar in patients with severe ventricular dysfunction. Several important implantable-cardioverter defibrillator (ICD) trials initially utilized thoracotomy ICDs. Although questions may be raised with regard to applicability of such a trial in the era of nonthoracotomy ICDs, this study suggests that the results of such ICD trials will be largely applicable to patients treated with nonthoracotomy ICDs.

Aged↗
PubMed1994

Nonthoracotomy- versus thoracotomy-implantable defibrillators. Intention-to-treat comparison of clinical outcomes.

BACKGROUND: Nonthoracotomy-implantable cardioverter/defibrillator (ICD) systems may represent a significant advance in the treatment of patients with life-threatening ventricular arrhythmias, but their merits relative to those of the well-established thoracotomy systems remain largely unknown. The objective of this study was to compare the short- and long-term clinical outcomes after attempted ICD implantation via a nonthoracotomy versus thoracotomy approach in similar groups of patients. METHODS AND RESULTS: Between September 1990 and December 1992, 212 consecutive patients underwent attempted ICD system implantation without concomitant cardiac surgery at a single institution. Approach selection was not randomized but rather was based primarily on hardware availability. Primary comparisons of short- and long-term outcome were performed according to the "intention-to-treat" principle. Implantation was attempted via a nonthoracotomy approach in 120 patients (57%) and via a thoracotomy approach in 92 patients (43%). Prior cardiac surgery was more prevalent in the nonthoracotomy patients; otherwise, groups did not differ significantly in terms of prognostically relevant clinical characteristics. Nonthoracotomy implantation was successful in 101 patients (84%). After crossover to thoracotomy implantation (14 patients), the eventual success rate for ICD system implantation was 96% in the nonthoracotomy group. Thoracotomy implantation was successful in 89 patients (97%). Operative mortality was 3.3% in the nonthoracotomy and 4.3% in the thoracotomy groups (P = .73). Nonthoracotomy group patients were less likely to experience postoperative congestive heart failure (6% versus 16%; P = .02) or supraventricular arrhythmia (6% versus 18%; P = .004) and had significantly shorter postoperative intensive care and total hospitalization. Total hospital costs were significantly lower in the nonthoracotomy group ($32,205 versus $37,265; P = .001). After a follow-up of 16 +/- 9 months, there were 17 deaths in the nonthoracotomy group (none sudden) and 12 deaths in the thoracotomy group (1 sudden). One- and 2-year Kaplan-Meier survival probabilities were .87 (95% CI, .78 to .91) and .80 (95% CI, .68 to .88) in the nonthoracotomy group and .90 (95% CI, .82 to .95) and .87 (95% CI, .77 to .93) in the thoracotomy group (P = .56; log-rank test). CONCLUSIONS: Nonthoracotomy ICD implantation is associated with reduced surgical morbidity, postoperative hospital care requirement, and hospital costs and has similar efficacy in preventing sudden death relative to the thoracotomy approach. From these nonrandomized data, it appears that a nonthoracotomy approach should be considered preferable in most patients requiring ICD therapy.

Aged↗
PubMed2004

[Video-assisted thoracoscopic surgery as an alternative to urgent thoracotomy following open chest trauma in selected cases].

OBJECTIVES: To prove that video-assisted thoracoscopic surgery in selected cases is an alternative to urgent thoracotomy following open chest trauma. MATERIALS AND METHODS: Retrospective analysis of case reports of patients operated for open chest trauma during 1997-2002. Comparison of two methods of surgical treatment: urgent video-assisted thoracoscopy and urgent thoracotomy. Duration of drain presence in the pleural cavity, duration of postoperative treatment, pain intensity and cosmetic effect were evaluated. Data analysis was performed using SPSS statistical software. Statistical evaluation of differences between groups was performed using Mann-Whitney U test. The differences between groups were considered to be statistically significant when the probability of deviation was p<0.05. RESULTS: During 1997-2002, 121 patients with open chest trauma were operated. Thirty three patients underwent urgent video-assisted thoracoscopy, 88 patients were operated through thoracotomy incision: 69 due to isolated open chest trauma, 17 due to thoracoabdominal injury and 2 due to abdominothoracic injury. Almost thirteen percent (12.5%) of patients after urgent thoracotomy underwent urgent laparotomy due to damaged diaphragm and other organs of peritoneal cavity. Duration of drain presence in the pleural cavity after video-assisted thoracoscopy was 4.57 days and after urgent thoracotomy - 6.88 days (p<0.05). Duration of post-operative treatment after video-assisted thoracoscopy was 8.21 days and after urgent thoracotomy - 14.89 days (p<0.05). Amount of consumed non-narcotic analgesics after video-assisted thoracoscopy was 1056.98 mg and after urgent thoracotomy - 1966.70 mg (p<0.05). CONCLUSIONS: Video-assisted thoracoscopy is minimally invasive method of thoracic surgery allowing for the evaluation of the pathological changes in the lung, pericardium, diaphragm, mediastinum, thoracic wall and pleura, including the localization of these changes, and the type and severity of the injury. The number of early post-operative complications following video-assisted thoracoscopy is lower. Compared to operations through thoracotomy incision, video assisted thoracoscopies entail the shortening of the duration of drain presence in the pleural cavity and the duration of post-operative treatment. Video-assisted thoracoscopy should be performed on all patients with open chest trauma and stable hemodynamics and the respiration function. Video-assisted thoracoscopy is an informative diagnostic and treatment method allowing for the selection of patients for urgent thoracotomy.

Abdominal Injuries↗
PubMed2005

[Right subaxillary and posterolateral thoracotomy for open repair of congenital heart defects].

OBJECTIVE: Low-risk cardiac surgery approaches zero morbidity/mortality, therefore, cosmetic issues append. Right thoracotomy has been advocated as cosmetically attractive alternative to median sternotomy. Posterolateral thoracotomy involves chest wall musculature division that contributes to postoperative pain/morbidity; access to the heart may be difficult. Longitudinal subaxillary incision and muscle-sparing thoracotomy can overcome these disadvantages and provide better visibility. PATIENTS AND METHODS: Between April 2000 and April 2004 the authors performed open-heart repair from right thoracotomy in 161 patients. Diagnoses comprised perioval and sinus venosus ASDs (137), VSD (11), incomplete/intermediate AVD (8), miscellaneae (5). According to both patients' and surgeon's preference a longitudinal midaxillary incision and muscle-sparing lateral thoracotomy was utilised in 98 cases. Intracardiac repair was performed by extracorporal circulation, usual cannnulation, cardioplegia. Data of 79 ASD closures via midline sternotomy were used as controls. RESULTS: Sternotomy and thoracotomy groups did not differ in demographic characteristics albeit thoracotomies exhibited wider age and weight range. The skin incision could be easily stretched up by 60% providing excellent visibility/access. No mortality occurred. Phrenic nerve palsies (2), transient tetraparesis (1) fully recovered. A mitral valve replacement was necessary for valve pathology unrelated to access. No breast and/or upper limb vascular/neurologic problems were encountered. CONCLUSIONS: Right subaxillary muscle-sparing thoracotomy offers safe option for open-heart repair of selected anomalies. Despite the shorter skin incision subaxillary approach provides better visibility than conventional thoracotomy as mediastinal organs are closer to the operator. Intermediate cosmetic result are appealing. With no muscles divided less postoperative pain is anticipated. The authors recommend to expand the spectrum of anomalies repaired via this approach.

Axilla↗
PubMed1992

Survival after emergency department versus operating room thoracotomy for penetrating cardiac injuries.

The authors undertook a 6-year retrospective review to assess their experience with penetrating cardiac injuries. Special emphasis was placed on identifying patients with and without tamponade and those requiring emergency department (ED) thoracotomy. Forty-eight patients were identified. Overall survival was 64.6 per cent. Thirty-three patients had tamponade, with 20 requiring ED thoracotomy. Fifteen patients did not have tamponade and two of these needed ED thoracotomy. Five patients who had ED thoracotomy were long-term survivors (22.7%). The remaining 26 patients, 13 with tamponade and 13 without, received operating room (OR) thoracotomy and all survived. The data shows that excellent results are possible with OR thoracotomy for penetrating cardiac injuries, with or without tamponade. However, results are not as good when ED thoracotomy is necessary. This may relate to the severity of the injury, the duration of tamponade, or the inability to control cardiac bleeding during thoracotomy in the ED setting. Even though survival is low with ED thoracotomy, it is high enough to continue to support its use in the deteriorating patient with a penetrating cardiac wound.

Adolescent↗
PubMed1992

Exigent postinjury thoracotomy analysis of blunt versus penetrating trauma.

We reviewed the recent experience with urgent thoracotomy performed in the operating room (OR) to compare the relative indications and injury pattern after blunt versus penetrating trauma. Among 2,316 patients admitted with acute trauma of the chest, excluding 319 undergoing thoracotomy at the emergency department, 83 required urgent OR thoracotomy; 27 patients (3 percent) sustained blunt trauma, 32 (4 percent) had stab wounds (SW) and 24 (7 percent) had gunshot wounds (GSW). The indications for operation after blunt trauma were shock (48 percent) and angiographically defined great vessel injuries (48 percent). For SW, thoracotomy was done for tamponade (50 percent), excessive chest tube output (28 percent) or shock (15 percent), and for GSW, thoracostomy output (50 percent), shock (25 percent) or tamponade (12.5 percent). Descending thoracic aorta (DTA) or other arch vessel tears were confirmed in 48 percent of patients with blunt trauma requiring thoracotomy; the remaining had pulmonary (31 percent) or cardiac wounds (7 percent). The most frequently encountered injuries in patients with SW were cardiac (46 percent) and pulmonary (37 percent), while the patients with GSW had predominantly pulmonary (72 percent) and cardiac (14 percent) injuries. The surgical management of blunt versus penetrating chest trauma differs with respect to the indications for urgent thoracotomy as well as the underlying injury pattern. The most common indication for urgent thoracotomy after penetrating injuries was excessive chest tube output (37.5 percent). Excluding torn DTA, only 14 of 822 patients (1.7 percent) admitted with blunt chest trauma required urgent thoracotomy and 13 of these patients (93 percent) presented in a state of refractory shock because of active thoracic hemorrhage. Thus, in contrast with penetrating wounds, urgent thoracotomy for blunt trauma is rarely justified on the basis of chest tube output alone.

Adult↗
PubMed2006

[Minimally invasive thoracotomy for the lung resection; without thoracoscopic procedure].

Video-assisted thoracoscopic surgery (VATS) is though to be a minimally invasive surgical procedure of lung resection. But there are some problems still remained about training, cost efficacy and oncological principles. Minimally invasive thoracotomy without thoracoscopic procedure was reviewed in this paper. In case of standard posterolateral thoracotomy with cutting ribs, it brings less postoperative pain and less dislocation of the ribs that fixes the ribs with bioabsorbable poly-L-lactide (PLLA) pins. Muscle sparing thoracotomy is available in broadly peeling off the muscle of trapezius and latissimus dorsi subcutaneously. But sometime much exudate collects subcutaneous wound in postoperative period so that some trouble or complication often occurs in the management of postoperative course. In case of axilloanterior thoracotomy we have proper view which is almost the same as standard posterolateral thoracotomy without cutting thoracic muscles. Skin incision runs from the axillar to the lateral margin of the breast and the 4th or 5th intercostal thoracotomy is performed through thoracodorsal muscle being pressed laterally, anterior serratus muscle being split. There is no need to cut the ribs, and good for the upper or middle lobectomy and the upper mediastinal dissection. Axilloanterior thoracotomy is minimally invasive than standard posterolateral thoracotomy and is useful for the surgery of upper or middle lobe lung cancer. In the procedure of thoracotomy operating with or without thoracoscope is not to be concerned. Important is to perform operation smoothly in adequate time for patients ease.

Humans↗
PubMed1994

Limited utility of emergency department thoracotomy.

To assess the therapeutic role and cost effectiveness of resuscitative thoracotomy in an urban trauma center, a retrospective review of thoracotomies (n = 273) performed in a trauma unit between 1986 and 1992 was undertaken. A total of 252 thoracotomies were performed for penetrating injuries (92%), and 21 (8%) were performed for blunt trauma. Ten neurologically intact survivors (3.7%) were identified. Mechanisms of injury in survivors were stab wound (n = 6) and gunshot wound (n = 4). There were no neurologically intact survivors when resuscitative thoracotomy was done for blunt trauma. All survivors sustained penetrating truncal injuries; isolated thoracic injuries existed in six patients, while four patients presented with both thoracic and abdominal wounds. All survivors had signs of life either in the field or in the trauma unit. Of the 242 non-survivors who had sustained penetrating trauma, only 49 had signs of life either in the field or upon arrival at the trauma unit. In this group, survival was 17 per cent. Revised Trauma Scores, calculated in the trauma unit, failed to differentiate between survivors and nonsurvivors. In 1992, the average hospital charge for resuscitative thoracotomy was $3413 per patient. Total charges during the study period for resuscitative thoracotomy were approximately $932,000. This represents an expenditure of $93,000 per successful thoracotomy. If thoracotomy was limited to patients sustaining penetrating trauma who demonstrated signs of life, total charges would be approximately $201,367, representing an expenditure of $20,137 per successful thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1985

Emergency thoracotomy in an urban community hospital: initial cardiac rhythm as a new predictor of survival.

Several authors have reviewed their experience with emergency thoracotomy in the university hospital setting. However, physicians in urban community hospitals are treating increasing numbers of patients who require emergency thoracotomy. To compare such experiences, the charts of all patients who underwent emergency thoracotomy in an urban community hospital during the years 1981 and 1982 were reviewed. In addition, the presenting cardiac rhythm was evaluated as a potential new prognosticator for survival in these patients. Forty-seven thoracotomies were performed during the two-year period. Thirty-nine (83%) were for penetrating trauma, of which 31 (66%) were for gunshot wounds and eight (17%) were for stab wounds. Eight patients (17%) underwent thoracotomy for blunt trauma. Of the 13 patients (28%) who survived and were discharged from the hospital, eight (17% of the total) had no neurological deficit. Twenty-five patients (53%) presented in sinus rhythm, 23 in sinus tachycardia, and two in normal sinus rhythm. All survivors beyond the operating room were in this group (P less than 0.001). Twenty-two patients (47%) presented in bradyasystolic rhythms, including bradycardia (four patients), agonal ventricular rhythm (five patients), ventricular fibrillation (three patients), and asystole (ten patients). None of these patients survived. The outcome data for community-hospital emergency thoracotomy are comparable with those of university centers where similar reviews were undertaken. The presenting cardiac rhythm is an accurate prognosticator of survival in patients undergoing emergency thoracotomy. Patients who present with sinus rhythms deserve aggressive resuscitation and emergency thoracotomy. Emergency thoracotomy does not improve the uniformly poor prognosis in patients presenting in bradyasystolic rhythms.

Adolescent↗
PubMed1993

The optimum timing of resuscitative thoracotomy for non-traumatic out-of-hospital cardiac arrest.

Open-chest cardiopulmonary resuscitation (CPR) is a promising method for non-traumatic cardiac arrest. In this preliminary study, we investigated the optimum timing of thoracotomy which brings high rate of return of spontaneous circulation (ROSC) and keeps the incidence of unnecessary thoracotomy minimal. Ninety-five adult patients with non-traumatic out-of-hospital cardiac arrest were analyzed. Of those, 26 patients were treated by the open-chest CPR in a prospective consecutive fashion. In this group, the ROSC rate was investigated in connection with the interval from hospital arrival, or ambulance call, to thoracotomy. Another 69 patients were treated by standard CPR. In this uncontrolled group, the interval from arrival at hospital to ROSC was investigated to define the 'natural hospital course' by the conventional treatment. Patient characteristics in the open-chest CPR group and the standard CPR group were similar. In the open-chest CPR group, 15 patients obtained ROSC. There was a tendency that the ROSC rate was highest in the patients with thoracotomy within 5 min of hospital arrival and declined as the timing of thoracotomy was delayed. Similar tendency was noted when the timing of thoracotomy was counted from the ambulance call. In the standard CPR group, only two patients obtained ROSC during the initial 5 min of hospital course. These results suggest that thoracotomy within 5 min of hospital arrival brings the highest ROSC rate while keeps the incidence of unnecessary thoracotomy acceptable.

Cardiopulmonary Resuscitation↗
PubMed2003

Is open thoracotomy still a good treatment option for the management of empyema in children?

BACKGROUND: The incidence of pediatric postpneumonic empyema increases, and there is little consensus on its management. Open thoracotomy has been linked with high morbidity and prolonged hospitalization. Our aim was to review the outcome after open thoracotomy and to provide a set of data for comparison with other treatment modalities. METHODS: Forty-four children (median age, 8 years, 2 months to 16 years) undergoing surgery for postpneumonic empyema between 1993 and 2002 in our unit were studied. RESULTS: The median time from onset of symptoms to admission in a pediatric unit was 8 days (range, 2 to 63 days), the median time from pediatric admission to surgical referral was 3 days (range, 0 to 19 days), and the median time from surgical admission to thoracotomy was 1 day (range, 0 to 2 days). Eight children had a chest drain before surgical admission. Six patients, who were referred late (19 to 69 days), had lung abscesses. A limited muscle sparing thoracotomy (44 patients), formal decortication (36 patients), lung debridement (5 patients), and lobectomy (1 patient) were performed. After thoracotomy, median time to apyrexia was 1 day (range, 0 to 27 days) and drain removal was 3 days (range, 1 to 16 days). A pathogen was isolated in 21 patients. There were no deaths. Four children with abscesses remained septic and had lobectomies (2 patients) and debridements (2 patients). The median postoperative hospital stay was 5 to 53 days. One child had postpneumonic empyema develop and had decortication 3 months postoperatively. At follow-up, all children were doing well and had satisfactory radiographs. The Kaplan-Meier 5-year and 10-year survival rate, freedom from any reoperation, and freedom from hospital readmission were 100%, 87%, and 98%, respectively. CONCLUSIONS: Open thoracotomy remains an excellent option for management of stage II-III empyema in children. When open thoracotomy is performed in a timely manner there is low morbidity and it provides rapid resolution of symptoms with a short hospital stay. However, delayed referrals may result in advanced pulmonary sepsis and a protracted clinical course. The late results are encouraging. Use of thoracoscopy or fibrinolysis should be considered on the basis of their own merit, not on the assumption of probable adverse outcomes after thoracotomy.

Adolescent↗
PubMedDate not supplied

Emergency thoracotomy: comparison of medical student, resident, and faculty performances on written, computer, and animal-model assessments.

OBJECTIVE: In clinical practice, thoracotomy and other critical emergency procedures are rarely required. Consequently, medical students and residents have difficulty acquiring procedural competency in these critical procedures. The authors developed objective written, computer, and animal-model assessments of thoracotomy procedural competency to permit comparison of the reliability and validity of these three procedural assessment modalities. METHODS: Thoracotomy procedural competency was evaluated for 18 persons at three levels of training (medical student, resident, faculty), using written, computer, and animal-model assessments. A prospective, sequential assessment design was used, with the examinees serving as their own controls. Procedural competency was defined in terms of performance time (animal time scale) and performance accuracy (written accuracy, computer accuracy, and animal accuracy scales) for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross-clamping). Level of training was the independent variable, and procedural competency scores were the outcome measures. Confounding variables included previous thoracotomy and computer experience. RESULTS: Computer and animal-model assessments produced reliable results (Chronbach's alpha > 0.50). The animal time scale and computer accuracy scale best reflected the expected skill differences among levels of physician training, providing support for construct validity. In contrast, written and animal accuracy scale scores did not significantly differ by level of physician training. Moreover, previous thoracotomy experience (i.e., number of procedures previously performed) was not a significant predictor of procedural competency. CONCLUSIONS: This study demonstrates that critical emergency medicine procedures can be evaluated reliably and validly using computer simulation and animal-model assessments. Neither previous thoracotomy experience nor knowledge of procedure content adequately predicts thoracotomy competency.

Animals↗
PubMed1991

Results of thoracotomy in osteogenic sarcoma with pulmonary metastases.

BACKGROUND Resection of pulmonary metastases may be followed by long term survival and now that it is an accepted method of treatment for patients with osteogenic sarcoma indicators of favourable prognosis are needed to aid the assessment of suitability for resection. This study compares the survival rates of patients who did and did not undergo resection of their pulmonary metastases and relates them to prognostic indicators. METHODS The study population was the 43 patients with osteosarcoma who developed pulmonary metastases out of the 111 patients with osteosarcoma treated by the Birmingham bone tumour treatment service during 1977-83. All patients who developed metastases confined to the lungs were considered for resection, thoracotomy being advised for all patients (provided that they were fit enough) who had metastases thought to be resectable even if they were multiple. RESULTS Of the 18 patients who did not have a thoracotomy, 15 died of disseminated disease after a mean interval of eight months; one patient died of cardiomyopathy and two are alive after 26 and eight months. Of the 25 patients who underwent thoracotomy in an attempt to resect metastases, three were found to have inoperable disease and died after a mean interval of 5.4 months from thoracotomy. Overall, after thoracotomy (repeated if necessary) there was a 20% survival at five years from the first thoracotomy. When survival was assessed with respect to the disease free interval and the number and bilaterality of the metastases no significant relationships were found. There was, however, a significant relation between survival and the position of metastases, patients with metastases confined to one lobe of the lung having a mean survival of 29.5 months, compared with 13.7 months in patients with disease in more than one lobe. CONCLUSION Thus patients who had a thoracotomy survived longer from the time of diagnosis of pulmonary metastasis than those not undergoing thoracotomy; metastases confined to one lobe predicted a better prognosis.

Adolescent↗
PubMed2005

Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: evaluation of indications and long-term outcome compared with conservative treatment and open thoracotomy.

STUDY OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) is effective for primary spontaneous pneumothorax. We sought to evaluate the outcome of VATS compared to conservative treatment and open thoracotomy, and to discuss the indications for VATS in primary spontaneous pneumothorax. DESIGN: Retrospective study. PATIENTS AND INTERVENTIONS: Primary spontaneous pneumothorax was diagnosed in 281 consecutive patients between January 1989 and April 2001. Mean age was 29.1 years. Mean follow-up period was 78.3 months (range, 13 to 163 months). For these patients, conservative treatment, open thoracotomy, or VATS were performed, and the outcomes of the three treatments were evaluated. If recurrence occurred, outcome of treatment for the recurrence was also evaluated according to the number of times of recurrence. RESULTS: Recurrences were observed in 109 of 281 patients (38.8%). Forty-three patients (15.3%) had repeat recurrences. Regarding the outcome of the first episode, recurrence rates were 54.7% for conservative treatment, 7.7% for open thoracotomy, and 10.3% for VATS. Recurrence rates after the second episode were 60.3% for conservative treatment, 0% for open thoracotomy, and 18.6% for VATS. Overall recurrence rates of each treatment were 56.4%, 3.0%, and 11.7%, respectively. There was no statistical difference between the open thoracotomy and VATS groups (p = 0.15). Hospital stays from operation until discharge were 11.5 days for open thoracotomy and 4.1 days for VATS (p < 0.001). CONCLUSION: The outcomes of VATS were very good compared to conservative treatment and equal to those of the open thoracotomy, not only for the first episode but also for the case of recurrence. In terms of low morbidity, low invasiveness, and cosmetic issues, VATS is superior to open thoracotomy. VATS is standard in cases of recurrence and should be considered for treatment at the first episode.

Adolescent↗
PubMed2000

Comparison of videothoracoscopy and axillary thoracotomy for the treatment of spontaneous pneumothorax.

Surgical treatment of spontaneous pneumothorax can be done through a thoracotomy or a video-thoracoscopic approach. Although the videothoracoscopic technique is currently popular it is not obviously superior to a more traditional axillary thoracotomy approach. We compared our recent experience with both techniques to determine the optimal surgical treatment for spontaneous pneumothoraces. A retrospective review of 79 patients treated surgically (34 thoracotomy and 45 thoracoscopy) for spontaneous pneumothoraces was done. Patients were treated between 1991 and 1997. Patients older than 60 years of age and those with spontaneous pneumothoraces secondary to generalized pulmonary emphysema were excluded. There were no operative deaths. Recurrence rate [thoracotomy, two of 34; thoracoscopy, three of 45 (P < 0.89)], air leak exceeding 7 days [thoracotomy, three of 34; thoracoscopy, three of 45 (P < 0.73)], operating room times [thoracotomy, 54 +/- 26 minutes; thoracoscopy, 53 +/- 16 minutes (P < 0.59)], and postoperative length of stay [thoracotomy, 5.7 +/- 4.3 days; thoracoscopy, 4.7 +/- 4.4 days (P < 0.26)] were not significantly different for the two techniques. We conclude that axillary thoracotomy and videothoracoscopy are equally effective surgical treatments for spontaneous pneumothoraces. A large randomized trial would be needed to determine whether one approach is truly superior to the other.

Adult↗