[The influence of thoracotomy on the chest wall movement--difference between intercostal thoracotomy and median sternotomy].
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Humans↗
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Resuscitative thoracotomy performed in the operating room.
The efficacy of resuscitative thoracotomy in the trauma patient has been questioned. Survival rates are variable, but a review of resuscitative thoracotomy in the emergency department of our institution documented an overall survival rate of only 1.8%. Higher survival rates may be anticipated in patients initially presenting with signs of life who can be transported directly to the operating room prior to the need for resuscitative thoracotomy. To test this hypothesis, the clinical course of all injured patients undergoing urgent or exigent thoracotomy in the operating room between July 1983 and June 1989 was reviewed. There were 34 patients undergoing exigent/resuscitative thoracotomy, 8 with penetrating injuries, 25 with blunt trauma to multiple systems, and 1 with isolated blunt chest trauma. Eight median sternotomies were performed and 26 left or bilateral thoracotomies. Twenty-six patients underwent concurrent exploratory celiotomy. The overall survival rate was 9% (3 of 34). The survival rate for patients with penetrating injuries was 37.5% (3 of 8) and 0% (0 of 26) for those with blunt trauma. Fifty-four patients underwent urgent/nonresuscitative thoracotomy with an overall survival rate of 74% (40 of 54). Combined group survival rates were 49% overall, 77% for patients with penetrating wounds, and 22% for patients with blunt trauma. These data underscore the futility of resuscitative thoracotomy in patients with blunt trauma who have deteriorated to the point of being in extremis. The relatively high salvage rates in patients with penetrating injuries support continued use of resuscitative thoracotomy when vital signs are lost, particularly if the injury is to the thorax. Variability in reported survival rates may be primarily due to the mix of patients with blunt trauma and penetrating injuries and disagreement as to what constitutes a resuscitative thoracotomy.
Adolescent↗
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↗
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↗
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↗
[Results of re-thoracotomy for the management of early postoperative complications after bronchoplastic operations].
We reviewed cases of re-thoracotomy performed for early complications after bronchoplastic procedures. One hundred and sixteen bronchoplasties were performed in our department over 20 years. The diseases for which bronchoplasty was undertaken were lung cancer in 102 patients (87.9%), tuberculous stenosis of the bronchus in eight, esophageal cancer in three, and trauma in three. The most frequent postoperative complication was difficulty of expectoration and atelectasis, which generally improved with conservative treatment. Re-thoracotomy was performed for early postoperative intrathoracic complications on 11 patients. The reasons for re-thoracotomy were bronchial anastomotic dehiscence in five cases, obstruction of bronchial anastomosis in two, atelectasis in two, and occlusion of anastomosis of pulmonary arterial angioplasty in two cases. All except two underwent re-thoracotomy within two weeks of the first operations. The operative procedures performed were completion pneumonectomy in six cases, re-bronchoplasty in three, suture of anastomotic dehiscence in two, patch closure of pericardial defect with aspiration of secretions in the atelectatic lobe in one, and partial decortication with suture closure of the alveolar fistula in one. Pedicled omental wrapping was applied to two patients with re-bronchoplasty and one with completion pneumonectomy. Post-operative complications after re-thoracotomy were anastomotic insufficiency in two cases, bronchopleural fistula in two, and pneumonia in one. Two patients underwent a third thoracotomy. There was no anastomotic dehiscence or bronchopleural fistula in the patients with pedicled omental wrapping. One patient died due to bronchopleural fistula within 30 days of re-thoracotomy. Six patients died of recurrence or pneumonia from 39 days to one year after re-thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
Bronchi↗
Pulmonary gas exchange and ventilation-perfusion relationships during hypocapnia and thoracotomy in anaesthetized dogs.
The effects of hypocapnia and thoracotomy, both individually and combined, on pulmonary gas exchange and distribution of ventilation-perfusion ratio (Va/Q) were studied in anesthetized and paralyzed mongrel dogs by the six inert gas elimination technique. Normocapnia (PaCO2 35 mmHg) and hypocapnia (PaCO2 20 mmHg) were produced sequentially by varying the inspired CO2 concentration. Thoracotomy was performed at the fourth intercostal space. When ventilation was changed from normocapnia to hypocapnia without thoracotomy, PaO2 decreased from 160 +/- 10 to 147 +/- 11 mmHg and Qs/Qt increased from 0.0 +/- 0.0 to 0.6 +/- 0.7%. However, no change was observed in perfusion distribution following thoracotomy during normocapnia, PaO2 decreased from 160 +/- 10 to 113 +/- 15 mmHg together with a shift of perfusion toward the low Va/Q region. However, no change was observed in Qs/Qt. When ventilation was changed from normocapnia to hypocapnia with thoracotomy, PaO2 decreased from 113 +/- 15 to 98 +/- 12 mmHg and Qs/Qt increased from 0.3 +/- 0.8 to 3.4 +/- 2.0%. After thoracotomy, a shift of perfusion toward the low Va/Q region was observed, which was probably responsible for the decrease in PaO2. The decrease in PaO2 during hypocapnia was due to an increase in the true shunt rather than the development of low Va/Q region. Hypocapnia combined with thoracotomy produced a further reduction of PaO2 and a greater increase in Qs/Qt.
Anesthesia, Intravenous↗
Emergency thoracotomy: survival correlates with physiologic status.
Emergency thoracotomy is a standard procedure in the management of cardiac arrest in patients sustaining severe trauma. We examined the records of 463 moribund trauma patients treated at our institution from 1980 to 1990 to refine indications for emergency thoracotomy. Patients underwent thoracotomy either in the emergency department (ED) (n = 424) or in the operating room (OR) (n = 39) as a component of continuing resuscitation after hospital arrival. The survival rate was 13% (61 of 463) overall, 2% (3 of 193) for blunt, 22% (58 of 269) for all penetrating, 8% (10 of 131) for gunshot, 34% (48 of 141) for stab-wound patients, and 54% (21 of 39) for patients who underwent emergency thoracotomy in the OR. Survival correlated with the physiologic status of patients both on initial evaluation in the field by paramedics and on arrival at the ED. Patients with penetrating trauma and in profound shock (BP less than 60 mm Hg) or mild shock (BP 60-90 mm Hg) with subsequent cardiac arrest had survival rates of 64% (27 of 42) and 56% (30 of 54), respectively. None of the patients with absent signs of life, defined as full cardiopulmonary arrest with absent reflexes (n = 215), on initial assessment by paramedics in the field, survived. We conclude that (1) no emergency thoracotomy should be performed if no signs of life are present on the initial prehospital field assessment; (2) emergency thoracotomy is an indicated procedure in most patients sustaining penetrating trauma; (3) blunt traumatic cardiac arrest is a relative contraindication to emergency thoracotomy.
Adult↗
[Minor thoracotomy for the treatment of spontaneous pneumothorax].
We have recently established the following therapeutic principles for spontaneous pneumothorax, and have obtained favorable results. 1. All patients, including those with a first episode, are subjected to thoracotomy. 2. The standard technique is minor thoracotomy through a skin incision of 5 cm which is aesthetically superior, except complicated cases with chronic obstructive lung disease in elderly patients or giant bullae. 3. Bilateral simultaneous axillary minor thoracotomy is applied to bilateral pneumothorax, whether synchronous or metachronous. 4. Thoracotomy is attempted by other approaches when we preoperatively suspect pulmonary bullae in the lung bases or diaphragm. In the past three years (1988 to 1990), 68 out of 70 cases (97.1%) of spontaneous pneumothorax admitted to our department were operated on. Of them, 55 cases (81% of all surgical cases) underwent minor thoracotomy. Pleural abrasion was performed in order to prevent postoperative recurrence of the pneumothorax. The 55 cases of minor thoracotomy consisted of 51 males and 4 females aged 27.6 years on average (range: 15 to 64). In 22 cases (40%), this was the first occurrence, combination with hemothorax was seen in 4 cases, and bilateral simultaneous axillary minor thoracotomy was performed in 11 cases (20%). The location of the bullae was the upper lobe (or upper segment) in 95.5%, the middle lobe (or lingula) in 6%, and the lower lobe (S6) in 20%.(ABSTRACT TRUNCATED AT 250 WORDS)
Humans↗
Axillary thoracotomy.
The axillary thoracotomy should be the incision of choice for most uncomplicated general thoracic surgical procedures. It can be performed rapidly, avoids major muscle transection, and by employing a double lumen endotracheal tube will permit segmental resection as well as lobectomy without technical problem. One hundred consecutive, elective axillary thoracotomies were performed with minimal morbidity and only one mortality. Twenty-five of the patients were of high surgical risk. The larger posterolateral thoracotomy is reserved for repeat thoracotomy, Pancoast tumors, difficult procedures such as bronchoplasty and/or radical pneumonectomy, and when pleural symphysis is expected. Sometimes called lateral thoracotomy or mini-thoracotomy, the axillary thoracotomy is our most common incision.
Axilla↗
Does the surgical trauma of "exploratory thoracotomy" affect survival of patients with bronchogenic carcinoma?
A retrospective review was carried out to assess the possible adverse immunosuppressive effect of exploratory thoracotomy on the survival of patients with non-small cell carcinoma of the lung with N2 nodal metastases. Between 1960 and 1982, 48 patients with non-small cell bronchogenic carcinoma underwent exploratory thoracotomy; lung resection was not done because mediastinal lymph nodes were involved. The survival of these patients was compared with that of 64 patients in whom N2 disease was established by mediastinoscopy alone and who did not undergo thoracotomy. There were no significant differences with respect to age, sex, tumour type and adjunctive radiotherapy. There were slightly more T4 tumours in the thoracotomy group (50% versus 30%). The hospital stay was longer in the thoracotomy group (2.3 +/- 1.1 versus 1.5 +/- 0.9 months [mean +/- SD]). However, follow-up studies showed that, although these patients had a more traumatic procedure, the actuarial survival curves for the two groups were virtually identical, and the 12-month survival rates were less than 20% for both groups. The median survival was 6.0 months for the thoracotomy group and 7.0 months for the mediastinoscopy group. These findings failed to demonstrate an adverse immunosuppressive effect of thoracotomy on lung cancer patients.
Adult↗
[Thoracotomies in thoracic injuries--indications and results].
Most thoracic injuries can be treated adequately with intensive care, pleural drainage and judicious physiotherapy. From the total of 571 patients with severe thoracic injuries treated in the Surgical Department of the University of Cologne over the last 10 years, 14% of those with blunt trauma (BT) and 33% with penetrating trauma (PT) underwent thoracotomy. Thoracotomy for PT was usually performed earlier and gave better results than thoracotomy for BT. With one exception, all PT underwent thoracotomy in the first 24 h after admission. For thoracotomy carried out for BT however, 38% took place after 24 h and 21% after 5 days. Postoperative mortality for BT was 3 times higher than for PT (56% vs. 18%). Reasons for this are to be found in the severe thoracic and general injuries associated with BT. The surgical procedure will depend on the type and extent of the thoracic and general injuries and on the general condition of the patient.
Adolescent↗
[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↗
[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↗
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↗
Anatomical basis of modern thoracotomies: the latissimus dorsi and the "serratus anterior-rhomboid" complex.
The latissimus dorsi and the "serrato-rhomboid" complex are the muscles most often involved in present-day thoracotomies for lung surgery. The present anatomic study emphasizes: the continuity between the serratus anterior and the rhomboid levator scapulae mass as a wide muscular sheet with a deep common fascia, extending the serrato-thoracic space (of Gillis) to the vertebral column as the rhomboserrato-thoracic space (the levator scapulae is situated higher up, above the ordinary thoracotomy); the presence of a "composite fascia" in the posterior angle between the seratus anterior and the rhomboid; the long costal attachment area and the presence of two differently oriented layers for the muscular digitations of the middle and inferior parts of the serratus anterior. With a rich vascular supply from multiple sources, the serratus anterior and latissimus dorsi are two large flat muscles with a single longitudinal nervous pedicle proceeding from the brachial plexus. To avoid esthetic (winged scapula) and functional sequelae, it is imperative to safeguard this single innervation as far as possible : by halting division of the serratus anterior before reaching its neurovascular pedicle in lateral or anterolateral thoracotomy, and by transecting the latissimus dorsi very low down in standard postero-lateral thoracotomy. The other muscles are simply freed and retracted.
Humans↗
Intrapleural analgesia for post-thoracotomy pain and blood levels of bupivacaine following intrapleural injection.
An epidural type catheter was placed in the pleural space under direct vision before the closure of the chest in 24 patients who underwent thoracotomy for various types of lung or aortic surgery. All patients received intrapleural injections of 20 ml of 0.5 per cent bupivacaine with or without epinephrine as initial pain therapy. Patients also received subsequent doses of a similar volume of 0.375 per cent bupivacaine with epinephrine 1:200,000 up to four times a day for a maximum duration of seven days. Good pain relief was achieved in patients who underwent lateral and posterior thoracotomies. No pain relief was achieved in patients who underwent anterior thoracotomy or in patients in whom there was excessive bleeding in the pleural space. Bupivacaine blood concentrations were measured in 11 patients following the initial dose of 20 ml of 0.5 per cent bupivacaine (with epinephrine 1:200,000 in five of the 11 patients). The mean peak plasma concentration of bupivacaine when used with epinephrine was 0.32 +/- 0.02 microgram.ml-1. The mean peak plasma concentrations of bupivacaine when used without epinephrine was 1.28 +/- 0.48 microgram.ml-1. Our present data show that intrapleural analgesia is useful in the management of postoperative pain in patients who undergo thoracotomy. Our data also show that there is a significant decrease in peak plasma concentrations of bupivacaine when epinephrine is added to the solution (P less than 0.05).
Adult↗
Emergency department thoracotomy for traumatic cardiac arrest.
There continues to be a debate on the indications for and value of emergency department thoracotomy, especially with regard to thoracotomies performed by emergency physicians. The current literature does not deal specifically with thoracotomies performed by an emergency physician on trauma patients in full cardiopulmonary arrest in a setting with no immediate surgical backup. This paper reports the results of 6 years of experience by one emergency physician in such a setting involving 80 patients, with a 6% overall survival rate, including two patients who survived blunt traumatic cardiac arrests. This lends support to emergency-physician-performed thoracotomies on trauma patients in "extremis," even in the setting of a hospital with no immediate surgical backup.
Adolescent↗