[Penetrating thoracic and abdominal injuries: diagnostic and therapeutic approach]

INTRODUCTION

Penetrating thoracic or abdominal or combined injuries are associated with high risk of life-threatening intraabdominal or intrathoracic organ injury. Most patients require acute surgery. When miniinvasive technique is available, thoracoscopic or laparoscopic intervention is indicated in hemodynamically stable patients to evaluate severity of the injury, as well as to treat the condition.

AIM OF THE STUDY

Retrospective analysis of incidence, diagnostics and treatment of penetrating thoracic and abdominal injuries and combined thoracoabdominal injuries in a Trauma centre.

PATIENTS, METHODS AND RESULTS

A total of 195 patients with penetrating thoracic, abdominal or combined injuries, who were hospitalized in the FNKV (Krilovské Vinohrady Faculty Hospital) Trauma centre in Prague from 1999 to 2010, were included in the study. The study group included 177 (91%) males. Out of the total, 102 patients (53%) suffered from penetrating abdominal injuries, 71 (36%) from thoracic injuries and 22 (11%) from combined, thoracoabdominal injuries. The majority of injuries were stab injuries (173, i.e. 89% of the patients). 22 subjects, the penetrating injury was caused by shot injuries. In stable patients, MDCT has been lately used to establish the diagnosis. In 171 subjects, acute thoracotomy or thoracotomy was indicated. Patients with combined injuries of the both cavities were indicated either for thoracotomy and laparotomy or thoracophrenolaparotomy. Videothoracoscopy or laparoskopy was conducted in 21 (11%) of the subjects. During the surgical revision, two subjects exited due to ireversible hemorrhagic shock, further 2 subjects died because of septic complications following shot abdominal injuries.

CONCLUSION

Incidence of penetrating thoracic, abdominal or combined thoracoabdominal injuries is fairly rare in our country. Subjects with unstable hemodynamic conditions are indicated for acute thoracotomy or laparotomy. Miniinvasive procedures have diagnostic and therapeutic benefit in stable patients. Diagnostic thoracoscopy and laparocopy provides evidence of some injuries (diaphragm, alimentary tract). Therapeutically, miniinvasive methods may be used to manage the source of bleeding and for targeted drainage. Nonsurgical procedure is the method of choice in a selected group of hemodynamically stable patients with stab injuries, with monitoring of the patient's condition, including the use of x-ray imaging.

[The role of VATS in the treatment of thoracic empyema]

INTRODUCTION

Videothoracoscopy (VTS) and video-assisted thoracoscopic (VATS) decortication is commonly used in the treatment of early thoracic empyema. However, its conversion to thoracotomy is more frequent in chronic empyema cases. The authors evaluate the role of VTS/VATS in the pleural empyema therapy in the group of patients treated for thoracic empyema using VATS or thoracotomic decortication.

PATIENTS, METHOD AND RESULTS

The retrospective study included 165 patients who underwent surgery for thoracic empyema. Pneumonia was the the commonest cause of pleural empyema (77%), while elective lung and esophageal surgery resulted in pleural empyema in 11% of the subjects, trauma in 9% and intraabdominal infection in 3% of the subjects. The subjects were diagnosed with thoracic empyema stage II or III either prior to the procedure on CT examination, or during the procedure. VTS/VATS was indicated in 52 subjects, and conversion to open decortication was required in 23 of them. Open thoracotomic decortication was performed in 113 subjects. VTS/VATS was successful in stage II disorders, in particular in the removal of pus and fibrin, with targeted chest drain insertion. VATS decortication was performed in 15 subjects with stage II or early stage III disorders. In open decortications, the procedure was extended to lung resection (8x lobectomy and 10x wedge non-anatomical resection) for residual abscess pneumonia or lung abscess. Conservatively managed postoperative complications included protracted chest drain air leak (11 patients) and fluidothorax relapses which were treated with redrainage (8 patients). Early postoperative rethoracotomy was indicated in 6 patients for hemothorax, resulting from hemocoagulation disorder in septic conditions. 4 patients were indicated for rethoracotomy for empyema relapses. During the postoperative period, 6 patients exited in the open decortication group.

CONCLUSION

VTS is the method of choice in the treatment of stage II thoracic empyema, with a potential for the infectious focus removal, targeted drainage and lung reexpansion. VATS is an alternative thoracotomy method for decortication in the early stage III empyema. Decortication via thoracotomy is a standard treatment method for the management of chronic empyema.

[A combination of dexmedetomidine with ketamine and opioids results in significant inhibition of hemodynamic changes associated with laparoscopic cholecystectomy and in prolongation of postoperative analgesia]

THE AIM OF THE STUDY

Recently, alpha2 sympathoadrenergic drugs are used in premedication to improve the perioperative course. The aim of our study was to compare a premedication with a new alpha2 sympathoadrenergic drug and standard premedication.

METHODS

After ethic committee approval and written patient consent, in a randomised, double-blinded study, combination of dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + fentanyl 1.0 microg x kg(-1) + atropine 0.5 mg (group FNT), dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + alfentanil 5.0 microg x kg(-1) + atropine 0.5 mg (group ALFNT), or pethidine 1.0 mg x kg(-1) + atropine 0.5 mg (group Dolsin) was administered to a deltoid muscle 15 min. before anaesthesia (GA) in patients elicited for laparoscopic cholecystectomy (LCHE). GA was performed in a standard way, ECG, NIBP, respiration rate, SpO2, onset of effect, Observers Assessment of Alertness Sedation Score (OAASS) before GA, circulatory reaction to intubation and capnoperitoneum, fentanyl consumption during GA, time to the first request for post-operative analgesia and postoperative nausea and vomiting were measured. The data were processed by Kruskal-Wallis and Fisher tests. P-value < 0.05 was considered significant.

RESULTS

There were 16 patients in FNT and Dolsin and 15 patients in ALFNT with no differences in demography except for younger age in ALFNT. The main differences were in hypertension during capnoperitoneum: 0/16 FNT and 1/15 ALFNT vs. 11/16 Dolsin, both p < 0.001, per-operative fentanyl consumption: FNT 31.5 microg vs. Dolsin 165.0 microg, p < 0.001 and ALFNT 50.0 microg, p < 0.05 (ALFNT vs. Dolsin, p < 0.01) and request to the first analgesic post surgery: FNT 1.3 h. vs. Dolsin 0.45 h., p < 0.05 vs. ALFNT 0.8 h., p < 0.01. There were no differences in side effects except for bradycardia in ALFNT (p < 0.05).

CONCLUSIONS

Dexmedetomidine-ketamine-fentanyl-atropine combination is superior to pethidine-atropine combination in suppressing of adverse hemodynamic effects of capnoperitoneum, decreased need for analgesia during GA and prolonged postoperative analgesia.

[Leiomyoma of the abdomen wall. Case report]

Authors present the case report of the patient indicated to plastic of abdomen wall for large hernia. Per operation, tumor was found without communication with abdomen cavity and organs. Histopathologically, leiomyoma of the abdomen wall was identified.

[Contemporary approach to treatment of the posttraumatic empyema of the thorax]

INTRODUCTION

Empyema of the thorax is a serious morbidity and mortality causative factor in the postoperative period in severe blunt and penetrating thoracic injuries. The posttraumatic empyema of the thorax results, primarily, from secondary infections of the haemothorax. Current therapeutic management of the posttraumatic empyema of the thorax depends on the disease stage.

AIM

A retrospektive analysis of the treatment procedures in patients with posttraumatic empyemas of the thorax. MATERIAL, METHODS, RESULTS: A study group included 118 patients with empyemas of the thorax, who were operated during the period from 1996 - June 2005. The commonest type of the empyema was a parapneumonic empyema, present in 86 (73%) subjects. 15 (13%) patients were operated for posttraumatic empyemas of the thorax. In 13 (11%) patients the empyema followed elective intrathoracic procedures (lung or oesophagus resection). In 4 (3%) cases the empyema resulted from intraabdominal inflammatory disorders. The cause of the posttraumatic empyema of the thorax was a secondary infection following repetitive drainages for the pneumothorax in three patients, infection of the retinated haemothorax in two patients and infection of the pleural exudate from a subphrenic absces following a stab injury of the abdomen in one patient. Another patient developed empyema as a complication of the oesophagus perforation by a foreign body. 8 injured patients with ventilation pneumonias developed parapneumonic empyemas. The patients were indicated for surgeries. Videothoracoscopic procedures (VTS, VATS) proved successful in 4 injured patients with empyemas, stage II. Thoracotomy with decortication was conducted in the remaining 11 injured patients (in 3 of them as a VTS conversion). The postoperative course following the decortication in the injured group with the posttraumatic empyema was complicated by a protracted air leak with a partial pneumothorax in two subjects and by a relaps of the pleural exudate in one operated subject.

CONCLUSION

1. Open thoracotomy with empyemectomy and decortication is a standard treatment method in the thoracic empyema, grade III. 2. The videothoracoscopic procedures (VTS, VATS) are indicated in early forms of the grade II of the disorder. 3. The quality and the result of the therapy depend on the following: the management of the focus of the infection, as well as a sufficient lung expansion while the residual pleural cavity is being minimized and also the management of the air leak from the lung.

[Surgical management of varicose ulcers]

One of the most often diseases of the European population is the venous chronic leg ulcer. It requires a long-term and expensive therapy. Basic elements of the therapy are elastic banding of the leg, diuretics, antibiotics and local treatment. In some cases a profit can be acquired from surgical procedure, which includes the stripping and/or crossectomy of the saphenous vein or the subfascial ligation of insufficient perforators and skin grafting (two phases operation). This procedure shorts the time of therapy and prevents the ulcer recurrence, because it resolves the reason and the results of the disease. We present 22 patients treated by this cure during the last 3 years at our surgery department of the 3rd faculty of medicine Charles University in Prague. 21 patients (95.5%) are healed.