Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma. METHODS: A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI. RESULTS: One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound. CONCLUSIONS: In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.     

Endovascular treatment of aortic rupture by blunt chest trauma

BACKGROUND: The usual treatment of blunt aortic injury (BAI) is prompt surgery. Frequently severe injuries to the brain or lungs exclude further surgical treatment. The purpose of this study is to assess the feasibility of placing endovascular stent-grafts. METHODS: From 1992 through 1999, in our primary and referral trauma center, 26 acute BAI, 21 males and 5 females, mean age 40.2+/-16.3 yrs were diagnosed. The last 4 patients underwent prospectively endovascular repair with Talent endograft. Endoprosthesis parameters were measured on three-dimensional spiral CT reconstruction. While waiting for devices, blood pressure was aggressively lowered and aortic lesions were monitored by transesophageal echography. RESULTS: Stent-graft deployment was successful in all 4 patients. There were no complications of endoleak, stent migration, paraplegia or death. Angiographic exclusion was complete in all 4 patients. CT scans at a mean follow-up of 11+/-5 months showed complete healing of the aortic wall in all patients. CONCLUSIONS: For stable acute BAI, endovascular stent-graft repair is feasible and safe, and is an effective therapeutic alternative to open surgery. Because of the normal proximal and distal wall in aortic injuries, endoluminal treatment might be the therapy of choice in the near future.     

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??Objective:To discuss the methods of Endovascular aneurysm repair (EVAR) for artic arch aneurysm or dissection. Methods:From Sep.1998 to Feb.2006,63 cases related with the super??arch branches.Three methods were used in the lesions with left subclavain artery (LSA) invasion only,covering the LSA without reconstruction,LSA bypass before EVAR or covering LSA completely and then re??open it by endovascular technique.To the lesions with LSA and left common carotid artery (LCCA) invasion,a traditional bypass of LCCA and LSA was done before EVAR,or covering most of LCCA first,and then reconstructed it through LCCA by endovascular technique.To the lesions with three super??arch branches invasion,a bifurcated stent??graft was planted for reconstructing the artic arch. Results:LSA was treated in 54 cases,LSA and LCCA were treated in 8 cases and all of the super??arch branch arteries were treated in 1 case.All of the auxiliary techniques were enforced successfully.The primary average systolic pressure of left brachial artery was ??62.6±24.2??mmHg in cases without LSA reconstruction.The 30??days endoleak rate was 17.5%. Conclusion:Covering the LSA is safe to the patients with normal contraliteral vertebral and basilar artery.EVAR combined with supplementary techniques can expand the EVAR indications of aortic arch lesions.The long term result still keep in follow up.     

Aortic valve repair after blunt chest trauma: repair of traumatic aortic valve rupture

A frequent reason of admission to the emergency room is blunt chest trauma following car accidents. Chest injuries may cause a wide range of cardiac lesions, extending from myocardial contusion, to heart or great vessels rupture, to valvular lesions. We present a case of aortic valve rupture after blunt chest trauma.     

主动脉弓部病变腔内修复术的研究

目的探讨进行腔内修复术(EVAR)时头、臂动脉的处理方案。方法1998年9月至2006年2月,共63例EVAR涉及到头、臂动脉的处理。左锁骨下动脉的处理:一期部分或全部覆盖;不行重建;先外科重建,然后腔内覆盖;完全腔内重建。左颈总动脉的处理:先外科重建,然后腔内覆盖;腔内覆盖大部分,然后腔内重建。无名动脉的处理:先外科重建左颈总动脉和左锁骨下动脉,然后应用分叉支架型血管完全重建主动脉弓。结果54例仅须处理左锁骨下动脉,8例须处理左颈总动脉和左锁骨下动脉,1例须处理弓上3分支血管。所有辅助技术均取得成功。左锁骨下动脉未进行重建者术后左肱动脉平均收缩压(62.6±24.2)mmHg(1mmHg=0.133kPa)。EVAR后30d内漏发生率17.5%。结论对有选择的病人,一期覆盖左锁骨下动脉是安全的。通过辅助技术,可以扩大EVAR的手术适应证。长期结果须行进一步随访。     

Endovascular repair of aortic rupture due to trauma and aneurysm.

OBJECTIVES: to report a single centre experience with endovascular repair of the ruptured descending thoracic and abdominal aorta. DESIGN: prospective non-randomised study in a university hospital. MATERIAL and METHODS: between 1995 and 2000, endovascular treatment was utilised for 231 aortic repairs; in 37 cases (16%) endografting was conducted on an emergency basis for 21 ruptured infrarenal aortic aneurysms, 15 ruptured descending thoracic aortic lesions, and 1 ruptured thoracoabdominal aortic aneurysm. The feasibility of endovascular treatment and the prostheses' size were determined, based on preoperative spiral CT and intraoperative angiography, both obtained in each patient. RESULTS: endografting was successfully completed in 35 patients (95%). Primary conversion to open repair was necessary in 2 patients (5%). Postoperative 30-day mortality rate was 11% (4 deaths). No patient developed postoperative temporary or permanent paraplegia. In 2 patients (5%) primary endoleaks required overstenting and in 6 patients (16%) secondary surgical interventions were required. Mean follow-up was 19 months (1-70 months); three deaths occurred within three months postoperatively (1-year survival rate 81+/-6%). In one case, secondary conversion to open repair was necessary 14 months postoperatively. CONCLUSION: the feasibility of endoluminal repair of the ruptured aorta has been demonstrated. Endoluminal treatment may reduce morbidity and mortality, and may in time become the procedure of choice in certain centres. However, further follow-up is required to determine the long-term efficacy.     

微创外科与电视胸腔镜

外科是采用手术治疗疾病的学科。手术治疗疾病必然会产生创伤,尤其传统胸外科手术切口长、创伤大,给患者生理和心理带来较大的影响。长期以来,以较小的创伤达到较好的治疗效果一直是外科医生追求的目标。近年来随着高科技在医学领域的应用,以腔镜为代表的微创外科手术深受广大患者的欢迎,微创外科技术正在被愈来愈多的胸外科医生所接受,并得到推广和应用。[第一段]     

Incidence of arrhythmias after thoracic surgery: Thoracotomy versus video-assisted thoracoscopy

Atrial arrhythmias, especially supraventricular tachycardia (SVT) and atrial fibrillation, are common after thoracotomy and lung surgery. There are few existing data on the incidence of postoperative arrhythmias after video-assisted thoracoscopy (VAT). The purpose of the present investigation was to retrospectively determine the incidence of postoperative arrhythmias in patients who underwent VAT compared with those who underwent thoracotomy, and which factors are associated with an increased risk for arrhythmias in both groups. A retrospective investigation. A metropolitan university hospital. The medical records of 124 patients who underwent thoracotomy and 81 patients who underwent VAT over a 2-year period were reviewed.

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There was a 17% incidence of atrial arrhythmias after thoracotomy and 10% after VAT, but the difference was not statistically significant. In both groups, atrial fibrillation was the most common atrial arrhythmia. Patients receiving digoxin were at higher risk for postoperative arrhythmias. Patients older than 65 years were at risk for arrhythmias after thoracotomy and patients older than 80 years were at risk for arrhythmias after VAT. Patients who had postoperative arrhythmias had prolonged hospital stays compared with patients who did not have arrhythmias.     

Multiple intracardiac lesions after blunt chest trauma

Closed chest trauma can cause rupture of intracardiac structures. We report the case of a 17-year-old boy whose chest was trodden by a horse. He sustained rupture of tricuspid and aortic valve leaflets and rupture of the interventricular septum. He underwent surgical repair of these lesions, but aortic insufficiency developed 2 years later and the aortic valve was replaced with a mechanical prosthesis.     

Endovascular repair of abdominal aortic aneurysms and other arterial lesions

Purpose: This report describes our experience with endovascular stented graft repair of abdominal aortic aneurysms and other arterial lesions.Methods: Between September 1990 and April 1994, 57 patients were treated with endovascular stented grafts (50 with abdominal aortic aneurysms or iliac aneurysms; five with traumatic arteriovenous fistulas; one with an infected femoral false aneurysm; and one with a false aneurysm of the proximal right common carotid artery). The devices consist of either a Dacron or an autogenous vein graft sutured to a balloon-expandable stent. The stented grafts are placed through remote arteriotomies, advanced under fluoroscopic guidance to their predetermined sites, and secured into position.Results: Forty of the 50 endovascular stented graft procedures used to treat abdominal aortic aneurysms or iliac aneurysms were considered successful, even though some secondary treatment was required in six patients (two open operations; four secondary endovascular procedures). The 10 failures include four early procedural deaths, one late procedural death, and five leaks. All five arteriovenous fistulas and the two false aneurysms were successfully treated with endovascular stented grafts.Conclusions: Although our experience with endovascular stented grafts has been promising, remaining problems require resolution, and further follow-up is needed. However, the potential advantages of these endovascular grafts warrant their continued evaluation. (J VASC SURG 1995;21:549-57.)     

腹主动脉瘤血管腔内治疗与开放手术治疗的疗效比较

目的 比较腹主动脉瘤血管腔内治疗与开放手术治疗的近期疗效。方法 对34例肾下型腹主动脉瘤患者的临床资料进行分析，比较腔内治疗组（15例）与传统开放手术治疗组（19例）的术前状况、手术相关情况、术后并发症、死亡率及手术前后的实验室检查数据。结果 腔内组术中出血量和输血量明显少于手术组（P=0．005、P=0．015），腔内组术后平均禁食时间和平均住院时间较手术组明显缩短（P〈0．0l、P：0．001）。手术组术后并发症发生率明显高于腔内组（P〈0．01）。术后第3天白细胞计数腔内组明显低于手术组（P=0．020）；术后第5天红细胞计数及血肌酐水平在腔内组均明显高于手术组（P=0．011、P=0．034）。结论 腹主动脉瘤血管腔内治疗具有安全、微创、对人体内环境干扰小的优点，近期疗效较传统开放手术好。     

Endovascular surgery for failed open aortic aneurysm repair.

OBJECTIVE: Determine the usefulness of endovascular surgery for repair of aortic lesions late after open surgical repair. PATIENTS AND METHODS: A retrospective analysis of our databank (Patient Analysis and Tracking System, Dendrite, UK) for 2000-2002 showed 286 descending thoracic and/or abdominal aortic aneurysms: 60/286 (21%) descending thoracic, and 255/286 abdominal (89%). Endovascular surgery was planned in 98 patients (17/60 (28%) for thoracic lesions, and 81/255 (32%) for abdominal lesions). 13/98 patients (13%) underwent endovascular surgery late after failed open aortic repair: 4/13 at the level of distal aortic arch (3/4 for false aneurysms post-coarctation repair), 4/13 at the level of the descending thoracic aorta (3/4 for false aneurysms proximal to the previous graft), and 5/13 at the level of the infrarenal abdominal aorta (4/5 for false aneurysms proximal to the previous graft). Endovascular surgery included per procedural target site identification (previous graft) with intravascular ultrasound (IVUS) under fluoroscopic control (no angiographies), controlled hypotension (partial inflow occlusion with a right atrial balloon introduced through a femoral vein) for unloading of covered endoprostheses in the thoracic aorta, as well as in situ introducer sheath dilatation in case of complex access to the aorta. RESULTS: There were no hospital deaths and no parapareses or paraplegias in this small series of patients who underwent endovascular surgery for aneurismal lesions occurring late after open repair. An endoleak type I was documented in 2/13 patients (15%) requiring a proximal extension in 1 patient. For the second patient with a minor endoleak, a control examination is planned at 6 months of follow-up. CONCLUSION: Endovascular surgery is an elegant approach for repair of recurring aortic lesions late after open aortic surgery. IVUS is a precious instrument for per procedural identification of the previous implants. However, long-term follow-up is mandatory after endovascular surgery.     

支气管封堵器在电视胸腔镜手术单肺通气中的应用研究

目的 评估支气管封堵器(endobronchial blocker,EBB)在电视胸腔镜手术中的应用效果. 方法 选择100例拟行择期电视胸腔镜手术(video assisted thoracoscopic surgery,VATS),完全随机分为EBB组(E组)和双腔支气管导管(double-lumen tube,DLT)组(D组),每组50例.观察比较两组患者的定位时间、肺塌陷时间、导管或EBB移位次数、肺隔离效果、气道压及下气道损伤情况. 结果 与D组比较,E组定位时间和肺隔离效果差异无统计学意义(P＞0.05).E组和D组肺塌陷时间分别为(8.5±3.5)、(4.5±2.9) min,套囊移位次数分别为23和5次,两组比较差异有统计学意义(P＜0.05);而D组患者单肺通气(one-lung ventilation,OLV)时压力显著高于E组,分别为(26±4)、(22±3) cm H20(1 cm H20=0.098 kPa);且其下气道中重度损伤例数也显著高于E组,分别为25和12例差异有统计学意义(P＜0.05). 结论 与DLT比较,EBB OLV术中肺萎陷时间长、位置易移动,但气道损伤小,能安全顺利地完成OLV,是满足VATS较好的OLV方法之一.