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PubMed1999

Changing indications for thoracotomy in blunt chest trauma after the advent of videothoracoscopy.

BACKGROUND: The advent of videothoracoscopy may restrict the indications for thoracotomy in blunt chest trauma. METHODS: We retrospectively compared two groups of patients with blunt chest trauma observed in consecutive periods, before and after the advent of videothoracoscopy, 989 patients from 1989 to 1993 and 908 patients from 1994 to 1998. RESULTS: During the first period, 38 thoracotomies were performed; but in 8 instances (21%), no major injuries were found. In the second period, 36 videothoracoscopies were performed to repair the lung (n = 5) or diaphragm (n = 5), to evacuate clots (n = 4), pericardial effusion (n = 3), and empyema (n = 2). Six procedures were converted and 11 findings were negative for lesions. Only nine intentional thoracotomies were performed, and significant lesions were found in each case. CONCLUSION: Videothoracoscopy has reduced the number of thoracotomies performed. Thoracotomy can be limited to massive bleeding with hemodynamic instability, major air leak, radiologic evidence of mediastinal enlargement or diaphragmatic rupture, or major anterolateral flail chest.

Adolescent↗
PubMed2001

Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series.

OBJECTIVE: The purpose of this study is to present the rationale for an algorithm that describes the place of resuscitative thoracotomy in the prehospital management of a patient with penetrating chest injury, and to review a 6-year experience using this algorithm. METHODS: This study was a retrospective review of all cases where a prehospital thoracotomy was performed by the medical teams of the London Helicopter Emergency Medical Service. RESULTS: Thirty-nine prehospital thoracotomies were performed. Four (10%) patients survived, one with long-term disability. Factors associated with survival were stab wound, single cardiac wound, cardiac tamponade, and loss of pulse in the presence of an experienced prehospital doctor. CONCLUSION: Current evidence suggests that patients who suffer a cardiac arrest more than 10 minutes away from emergency room thoracotomy are very unlikely to survive. Prehospital thoracotomy is associated with a small number of survivors. This intervention should be considered if there is an appropriately experienced, trained, and equipped doctor present, who is acting within a trauma system with ongoing training and quality assurance.

Adolescent↗
PubMed1998

Video-assisted thoracoscopic surgery versus open thoracotomy for anterior thoracic spinal fusion. A comparative radiographic, biomechanical, and histologic analysis in a sheep model.

STUDY DESIGN: In this in vivo investigation, a sheep model was used to compare the efficacy of a video-assisted thoracoscopic approach and a traditional thoracotomy in promoting a successful interbody spinal arthrodesis. OBJECTIVES: To compare the incidence of successful anterior spinal arthrodesis among three stabilization techniques-iliac crest, Bagby and Kuslich device, and Z-plate--performed using a video-assisted thoracoscopic approach and conventional open thoracotomy approaches. SUMMARY OF BACKGROUND DATA: A clinical outcome study on open versus endoscopic spinal fusion is not yet available. Moreover, no basic scientific investigations have been conducted to determine whether the success of an endoscopic arthrodesis is comparable to that of a conventional open procedure. METHODS: Fourteen Western Crossbred sheep underwent three identical destabilization procedures at T5-T6, T7-T8, and T9-T10, in which the anterior and middle osteoligamentous columns of the spine were resected, followed by three randomized reconstruction procedures using iliac autograft alone, and Z-plate stabilization with iliac autograft. In seven sheep, the entire destabilization-reconstruction procedure was performed using a video-assisted thoracoscopic surgical approach. In the remaining seven, the procedure was performed by conventional open thoracotomy. RESULTS: Histomorphometric and biomechanical evaluation demonstrated that the video-assisted thoracoscopic approach and open thoracotomy arthrodesis had comparable bone formation and biomechanical properties (P > 0.05). However, the Z-plate fusions, as a group, demonstrated increased flexion-extension stiffness properties and trabecular bone formation compared with the autograft and Bagby and Kuslich device fusions (P < 0.05). CONCLUSIONS: Thoracic interbody spinal fusions performed by thoracoscopy have demonstrated histologic, biomechanical, and radiographic equivalence to those performed by a thoracotomy approach. However, in the endoscopy group, intraoperative complications causing longer operative times, higher estimated blood loss, and increased animal morbidity indicated a substantial learning curve associated with the adoption of this surgical technique.

Analysis of Variance↗
PubMedDate not supplied

Effect of 5 cm of water positive end-expiratory pressure on arterial oxygen tension in dogs during and after thoracotomy.

Thoracotomy in dogs often is associated with lower than expected arterial oxygen tensions (PaO2). Pulmonary collapse from opening the thoracic cavity is likely to be responsible for decreased PaO2 during thoracotomy. To examine whether positive end-expiratory pressure (PEEP) is beneficial to dogs undergoing thoracotomy, PaO2 and hemoglobin saturation (SaO2) were measured in dogs randomly assigned to receive 5 cm of H2O PEEP (n = 7) or no PEEP (n = 9). During surgery in both groups of dogs, PaO2 progressively decreased (P < .001), but the decrease in PaO2 was significantly less in the PEEP group (P = .027). In both groups, PaO2 did not decrease enough to have a substantial effect on SaO2. Furthermore, application of PEEP during thoracotomy did not prevent moderate hypoxemia after surgery and discontinuation of PEEP. Application of 5 cm of H2O PEEP seems to attenuate the decrease in PaO2 observed in dogs undergoing thoracotomy, but routine application of PEEP does not seem justified.

Analysis of Variance↗
PubMed2004

Effect of cryoanalgesia combined with intravenous continuous analgesia in thoracotomy patients.

Fifty patients undergoing thoracotomy was studied to compare the effects of cryoanalgesia combined with intravenous continuous analgesia (IVCA). Patients were randomized into two groups: IVCA group and IVCA-cryo group. Subjective pain intensity was assessed on a visual analogue scale at rest (VAS-R) and during movement (VAS-M). Analgesic requirements were evaluated over the 7 days following surgery. Forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1) were measured before operation, on the 2nd and 7th postoperative days (POD). We interviewed patients by telephone to evaluate the prevalence of post-thoracotomy pain at the 1st, 3rd, and 6th months postoperatively. No significant differences were observed between the two groups with respect to postoperative pain, analgesic requirements, side effects, respiratory complications, or prevalence of post-thoracotomy pain. However, a significant increase in FVC and FEV1 was observed on the 7th POD in IVCAcryo group. The incidence of the post-thoracotomy pain at the 1st, 3rd, and 6th months postoperatively was 68, 60, and 44% in IVCA group, and 88, 68, and 28% in IVCAcryo group, respectively. Our study showed that cryoanalgesia combined with IVCA effectively restore respiratory function on 7th POD, but that it was not effective at reducing the incidence of post-thoracotomy pain.

Aged↗
PubMed1999

[Thoracoscopy versus thoracotomy. The dilemma of the comparison and its meaning for quality assurance in thoracic surgery].

The need for scientific investigation into the benefits of thoracoscopy in comparison to thoracotomy as well as State intervention to assure quality in the field of surgery motivated the members of the commission of endoscopic surgery of the German Society of Thoracic Surgery to conduct a pilot project at their hospitals. This pilot project was expected to analyse data on the outcome and a selection of variables concerning trauma and postoperative quality of life of some 400 patients treated between 8/95 and 10/95 at 5 thoracic surgical clinics. On completion of the pilot project the course of 141 patients undergoing different thoracic operations at 4 thoracic surgery departments had been documented to various degrees. 60 patients for various indications received a thoracoscopy, 72 a thoracotomy. In 9 patients thoracoscopy was converted to thoracotomy (6.4%). Eight of the 141 patients died in the postoperative course (5.7%), overall morbidity was 15.6%. There was a slight but statistically not significant difference concerning mortality and morbidity in favor of thoracoscopy (1.7 vs. 9.7% and 10 vs. 19.4%). But, there was a selection of malignant diseases, higher age and high risk patients towards thoracotomy. In subgroups of patients undergoing operations not bigger than the resection of three lung wedges only time of operation and length of incision revealed to be significantly shorter for thoracoscopy (69(25-190) min vs. 128(24-240)min, p = 0.0013; 6(4-8)cm vs. 23(12-35)cm, p = 0.0001). Borderline significance was reached by the Spitzer-Index in advantage for thoracoscopy (8(2-10)points vs. 7(0-10)points, p = 0.0728). Thoracotomy and thoracoscopy are access procedures used with different indications in different patients. Differences concerning trauma and quality of life if present are marginal and will need studies to be outlined. Quality assurance in thoracic surgery using a standardized documentation will not succeed under the given circumstances.

Adult↗
PubMed2005

[Intra-operative ketamine administration reduced the level of post-thoracotomy pain].

BACKGROUND: Two different types of post-operative pain (such as acute pain and chronic pain) occur in patients undergoing thoracotomy. It has been suggested that the acute post-thoracotomy pain consists of inflammatory pain and chronic post-thoracotomy pain caused by intercostal neuralgia. In the present study, we examined the effect of intra-operative administration of ketamine, an NMDA receptor antagonist, on the acute and chronic post-thoracotomy pain. METHODS: Sixteen patients were assigned to one of two groups (ketamine or control). The ketamine group received a ketamine bolus (1 mg x kg(-1)) just before the skin incision, followed by continuous infusion of ketamine (1 mg x kg(-1) x hr(-1)) during surgery. RESULTS: Verbal rating scores (VRSs) at rest and on cough were significantly lower in the ketamine group on day 1 and VRS of chronic pain was also significantly lower in the ketamine group 4 weeks after the surgery. CONCLUSIONS: These data suggest that post-thoracotomy pain might be mediated by NMDA receptor dependent central sensitization and that the intra-operative administration of ketamine might block the development of the NMDA receptor dependent central sensitization.

Aged↗
PubMed1991

[Trans-sternal bilateral thoracotomy for bilateral lung lesions].

The trans-sternal bilateral thoracotomy had been used widely in the early days of cardiac surgery, but since the 1960's the median sternotomy has played a great part in open heart surgery. Recently, the simultaneous bilateral thoracotomy has been used for bilateral lung lesions such as bilateral giant bullae, bilateral pneumothoraces and bilateral metastatic lung tumors. Since 1965 we have performed 6 operations using trans-sternal bilateral thoracotomy for several bilateral lung lesions. The diseases which led to the use of the trans-sternal bilateral thoracotomy technique were 2 cases of bilateral simultaneous pneumothoraces and 4 cases of bilateral lung metastatic tumors. The ages of the patients ranged from 17 to 45 years old. The operative blood loss was between 100 and 810 gm. No case showed postoperative respiratory distress or severe thoracic pain. It would like to be pointed out that the trans-sternal bilateral thoracotomy is the most ideal approach for the multiple bilateral lung metastatic lesions which often invade the chest wall or diaphragm.

Adolescent↗
PubMed1990

[Can we reduce the number of exploratory thoracotomies using mediastinoscopy?].

Between 1975 and 1988, 965 cases of bronchogenic carcinoma were submitted to surgery. A cervical mediastinoscopy (CM) was performed in 548 cases (57%). A nodal involvement was found in 35% of these 548 cases, thus 4 patients out of 5 did not undergo thoracotomy. One patient out of 5 underwent a thoracotomy in case of right ipsilateral and intranodal metastasis. Among 803 thoracotomies,-sixty were purely exploratories (7.5%), mainly because of a non resectable tumor. The rate of exploratory thoracotomy (ET) is decreasing (1975-1977 = 15%, less than 5% in recent years) as the rate of CM is increasing (1975-1979: 10-20%, 60-70% in recent years). The study of 60 cases of ET shows that 16 upon 39 performed CM revealed some nodal or mediastinal involvement. Nevertheless, among these 16 patients, the need of thoracotomy was under the pressure of necessity. Twenty-three patients had a negative CM: half of them had a left upper lobe carcinoma. Thus CM was inefficient to establish nodal mediastinal involvement in these cases.

Bronchial Neoplasms↗
PubMed1988

Survival after incomplete resection or exploratory thoracotomy in patients with advanced non small cell lung cancer.

In order to evaluate the effects of incomplete resection or exploratory thoracotomy on survival, 75 patients with Stage III non small-cell lung cancer (NSCLC) were studied. Twenty-five subjects underwent incomplete resection, 25 had exploratory thoracotomy and 25 patients who were denied surgery served as controls. Standard radio-therapy and chemotherapy regimens were given to most patients. The 2-year survival rates were 14%, 7% and 9% following incomplete resection, exploratory thoracotomy or conservative treatment, respectively. The survival curve was significantly worse in the exploratory thoracotomy group than in the control group (p less than 0.05). Major complications occurred in 2 patients after incomplete resection (bronchopleural fistula; chylothorax) and in 3 patients following surgical exploration (atelectasis). Two post-operative deaths were recorded in the exploratory thoracotomy group. In conclusion, the survival rate at 2 years in patients with Stage III NSCLC is not modified by incomplete or exploratory surgery. Moreover, exploration seems to worsen the outlook of patients during the first 2 years from diagnosis.

Carcinoma, Non-Small-Cell Lung↗
PubMed1987

[Penetrating chest injuries--an indication for early thoracotomy].

Indication for thoracotomy is undisputed in cases of gaping wounds with massive haemorrhage. However, discrete stab and gunshot wounds may quite often conceal imminent pericardial tamponade. Three quarters of all penetrating thorax injuries are located in or close to the cardiac silhouette. When it comes to patients with circulatory conditions of good stability, management of superficial wounds may cost valuable time and cause delay to thorough revision of the cardiac injury which usually would be possible without extracorporeal circulation. Success of that revision may then be limited due to tamponade-related impairment of cerebral perfusion and subsequent ischaemic brain damage. The risk implied in early exploratory thoracotomy was found to be low, as compared to the risk emanating from pericardial tamponade in cases of stab wounds in the cardiac region. Hence, early thoracotomy is generally indicated and should be generously decided to handle penetrating wounds of the chest. Superiority of early thoracotomy in handling penetrating thorax injuries is demonstrated in this paper by six of the authors' own patients. While relief of cardiac tamponade is possible by pericardiocentesis, immediate and safe restoration of blood volume through a central vein or the right atrium, control of haemorrhage, and definite repair of the cardiac defect can be achieved only by thoracotomy.

Adult↗
PubMedDate not supplied

Vertical axillary thoracotomy; a muscle-sparing approach for routine thoracic operations.

A standard posterolateral thoracotomy with division of the latissimus dorsi and serratus anterior muscles is associated with an important postoperative morbidity. A vertical axillary thoracotomy combining a vertical axillary skin incision with an intermuscular approach sparing both latissimus dorsi and serratus anterior muscles has the advantage of allowing full shoulder girdle motion early postoperatively as well as masking of the scar by the upper arm at rest. We report our experience with nine patients operated on with this approach for various intrathoracic lesions. All procedures were carried out without major difficulties. Wound healing was excellent in all patients. No infection nor seroma formation was seen with a submuscular suction drain. All patients had early and full shoulder girdle movement. No patient complained of late post-thoracotomy pain. We conclude that a vertical axillary thoracotomy provides an excellent cosmetic and muscle sparing incision which can be utilized for many thoracic procedures. However, we believe that, in the near future, video-assisted thoracoscopic surgery will become more popular than open thoracotomy for certain indications because of its distinct advantages of less postoperative morbidity.

Adult↗
PubMed1998

[Explorative thoracotomy in patients with bronchogenic carcinoma].

The authors analyse in a retrospective study a group of 31 patients with explorative thoracotomy, which was performed on account of inoperable bronchogenic carcinoma. The causes of inoperability were assessed and the period of survival after explorative thoracotomy was evaluated. From the total number of 496 patients indicated in 1985-1990 for surgery on account of bronchogenic carcinoma 465 pulmonary resections were made and 31 (6.25%) explorative thoracotomies. In all these patients the c TNM and p TNM classification was assessed. Disagreement in the evaluation of these parameters was found in particular in parameter T which was in agreement only in three instances. Conversely agreement was more frequent in parameter cN and pN (n = 18). The most frequent cause of inoperability was penetration of the tumour into the mediastinum (n = 25). Death within 30 days after surgery was not recorded in the group, three patients of 31 survived 5 years after exploration. Explorative thoracotomy did not exert a negative effect on the period of survival which corresponded to the given stage of the disease. Due to improving preoperative examination methods the number of explorative thoracotomies will probably decline in future, but at present it cannot be completely eliminated.

Adult↗
PubMed1998

Approach for primary mitral valve surgery: right anterolateral thoracotomy or median sternotomy.

BACKGROUND AND AIMS OF THE STUDY: Although both right anterolateral thoracotomy and median sternotomy have been used for mitral valve surgery (repair/replacement), the latter approach is considered standard for primary mitral valve surgery. We hypothesized that primary mitral valve surgery, if performed through a right anterolateral thoracotomy, would not only be better accepted cosmetically by patients, but also make redo surgery through a median sternotomy easy and trouble free from re-entry bleeding. METHODS: A right anterolateral thoracotomy was used for primary mitral valve surgeries in 52 patients (group A; 22 males, 30 females) of mean age 30.3 +/- 09.14 years (range: 14 to 50 years). Equal numbers of cases operated on during the same period by via median sternotomy were selected retrospectively from hospital records to serve as controls (group B). Groups were matched with respect to age, body weight, body surface area, sex, cardiac rhythm, functional status, type of mitral valve pathology and associated lesions. RESULTS: Operative mortality was similar in both groups, but fewer postoperative complications occurred in group A. Total hospital stay, intensive care unit stay, postoperative bleeding, inotrope requirement and ventilatory support postoperatively was significantly less in group A. CONCLUSIONS: Right anterolateral thoracotomy provides excellent exposure of the mitral valve, even with a small left atrium, and offers a better cosmetic lateral scar which is less prone to keloid formation. In addition, right anterolateral thoracotomy is as safe as median sternotomy for primary mitral valve repair/replacement, and should be used as an initial approach to mitral valve surgery, while median sternotomy be kept for repeat mitral valve or other open-heart surgery required later in life.

Adult↗
PubMed1985

Emergency thoracotomy: a four-year review.

The case records of 200 patients who had emergency thoracotomy for penetrating trauma were reviewed. The mortality was 47% (93/200) for the entire series, 27% (21/79) for stab wounds and 60% (72/121) for gunshot wounds. Of 55 patients who underwent thoracotomy in the emergency department, 8 (15%) survived. Twelve patients "dead" at the scene could not be resuscitated. Nineteen patients sustained cardiac arrest in the ambulance, 3 (16%) of whom survived. Of 19 who had cardiac arrest in the emergency department, 5 (26%) survived. Of 38 patients who had cardiac arrest in the ambulance or emergency department, 14 with stab wounds had a 43% survival and 24 with gunshot wounds had a survival of only 8%. Patients who underwent thoracotomy in the operating room (OR) had a higher survival, 68% (99/145). For those with thoracic, extremity, or neck injuries, survival was 81% (93/115). For those who had an OR thoracotomy for aortic cross-clamping because of abdominal injuries, survival was only 17% (5/30). Early thoracotomy has a place in the management of patients who have cardiac arrest in the ambulance or emergency department because of penetrating chest, neck, or extremity injuries, especially if caused by stab wounds. Cross-clamping of the thoracic aorta for massive abdominal bleeding should be applied selectively.

Adolescent↗
PubMed1982

Lateral thoracotomy and one-lung anesthesia in patients with morbid obesity.

Between May, 1980, and October, 1981, 22 morbidly obese patients ranging in weight from 93.4 to 236.8 kg (average, 145.2 kg) underwent transthoracic gastric stapling. Fourteen of these operations were performed using endobronchial intubation and selective collapse of the left lung to facilitate surgical exposure. The patients were compared with 22 consecutive patients treated by trans-abdominal gastric stapling during the same period. None of the 44 patients had evidence of chronic alveolar hypoventilation (pickwickian syndrome). In terms of operating time, blood loss, duration of intubation, and hospital stay, the two groups did not differ significantly. Despite marked shunting during one-lung ventilation, satisfactory arterial oxygen tension (PaO2) could be demonstrated on 100% oxygen for all thoracotomy patients (PaO2 range, 67 to 230 torr; mean, 132.3 torr). In fact, except for a lower PaO2 during one-lung anesthesia, the thoracotomy patients were indistinguishable from the laparotomy patients in terms of perioperative respiratory function. Pain, sedation, and positioning led to significant decreases in vital capacity and one-second forced expiratory volume in both groups on the first post-operative day, and in the thoracotomy group on the second day. There were only two wound infections in the thoracotomy group, as opposed to six infections with two dehiscences in the laparotomy group. It is concluded that lateral thoracotomy with or without one-lung anesthesia can be performed safely in massively obese patients--at least in those without preexisting alveolar hypoventilation syndrome.

Adult↗
PubMed1981

Aggressive thoracotomy for pulmonary metastatic osteogenic sarcoma in children and young adolescents.

During a 6-yr period, 57 children and young adults less than 21 yr of age underwent 111 thoracotomies for pulmonary metastatic osteogenic sarcoma. Follow-up after the initial thoracotomy averaged 36.8 no and ranged from 1 to 78 mo. Twenty-eight patients (49%) underwent more than one thoracotomy--the number of multiple thoracotomies averaged 2.9 and ranged from two to eight. Twenty-six of the 57 patients are currently alive, and 25 of these are free of disease. Median survival was 36 mo. Actuarial survival curves demonstrated a 5-yr survival of approximately 40%. Seventy-one percent of patients who had a tumor-free interval of greater than 1 yr are currently alive, compared with 39% of patients who had a tumor-free interval of less than 1 yr. Patients with disease confined to one lobe at the initial thoracotomy had a better survival (64%) than patients with diffuse or bilateral disease (41%). An aggressive surgical approach toward osteogenic sarcoma with pulmonary metastasis thus appears to be justified.

Actuarial Analysis↗
PubMed1987

Efficacy of emergency room thoracotomy in pediatric trauma.

With improved rapid transportation systems, an increasing number of children may arrive at the emergency room (ER) without detectable vital signs and may undergo vigorous resuscitation, including emergency room thoracotomy, aortic cross clamping, and open cardiac massage. Of 1,287 pediatric trauma admissions between 1980 and 1985, 101 deaths were recorded. Fifty (50%) of the deaths occurred in the ER. Thirty-three of the patients were pronounced dead with obvious irreversible injuries, while 17 (34%) with suspected thoracoabdominal injuries underwent ER thoracotomy during resuscitation. None of the 17 patients had detectable vital signs upon arrival to the ER. Fifteen patients had multisystem injuries associated with blunt trauma and two with isolated penetrating injuries. Despite maximal conventional resuscitation and ER thoracotomy, none of the 17 patients survived. In this group of pediatric blunt trauma victims who appear initially salvageable, and present in the ER with no detectable vital signs, ER resuscitative thoracotomy did not influence survival. ER thoracotomy in children, therefore, should be reserved for patients presenting with penetrating thoracic injuries or blunt injuries associated with detectable vital signs and deterioration despite maximal conventional therapy.

Adolescent↗