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Mashiko K, Matsumoto H, Yasumatsu H, Ueda T, Yamamoto M, Funaki Y, Toshimitsu Y. Emergent surgery for cardiac herniation coexisting with complex blunt cardiac injury: A case report. Trauma Case Rep 2021; 32:100464. [PMID: 33816745 PMCID: PMC8010855 DOI: 10.1016/j.tcr.2021.100464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/16/2022] Open
Abstract
A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V-V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.
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Affiliation(s)
- Kazuki Mashiko
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Hisashi Matsumoto
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Hiroshi Yasumatsu
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Taichiro Ueda
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Mariko Yamamoto
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Yutaka Funaki
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
| | - Yasuko Toshimitsu
- Shock & Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai-city, Chiba 270-1694, Japan
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Murakami K, Tanaka S, Hamaji M, Yoshizawa A, Date H. Successful resection of giant mediastinal tumor with growing teratoma syndrome by bilateral transmanubrial approach, clamshell and median sternotomy. Gen Thorac Cardiovasc Surg 2021; 69:1022-1025. [PMID: 33515399 DOI: 10.1007/s11748-021-01598-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/14/2021] [Indexed: 11/30/2022]
Abstract
A 25-year-old man was initially diagnosed with a giant mediastinal nonseminomatous germ cell tumor. Chemotherapy was administered and the tumor markers were normalized; however, the tumor grew in size (20 cm), invading the left brachiocephalic vein (BCV) and the superior vena cava (SVC). Bilateral transmanubrial approach with median sternotomy and bilateral clamshell thoracotomy was required for the complete resection of the giant tumor with the SVC reconstruction. Bilateral TMA provided the surgical field of view around the bilateral phrenic nerves and bilateral BCVs. Given the final pathological diagnosis of the mature teratoma, this was considered growing teratoma syndrome where surgery is the only treatment option.
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Affiliation(s)
- Kotaro Murakami
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Satona Tanaka
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
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Gaikwad NM, Srikrishna SV, Srikanth K. A rare case of a giant anterior mediastinal liposarcoma. Indian J Thorac Cardiovasc Surg 2020; 36:148-150. [PMID: 33061114 DOI: 10.1007/s12055-019-00871-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/27/2019] [Accepted: 09/01/2019] [Indexed: 11/28/2022] Open
Abstract
We report a case of a 53-year-old lady who was incidentally diagnosed to have giant anterior mediastinal mass while undergoing preoperative evaluation for another surgery. She came for surgery after 2 years when she became symptomatic. A large 6.7-lb (2800 g) tumor occupying both hemithoraces and engulfing heart was excised in its entirety through a clamshell thoracotomy under cardiopulmonary bypass standby. Histopathology revealed the final diagnosis as well as differentiated liposarcoma. She is now able to walk 2 km without any symptoms at the end of a 24-month follow-up.
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Affiliation(s)
- Namdeo Mahadeo Gaikwad
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, 258/A, Narayana Hrudayalaya, Bommasandra Industrial Area, Anekal Taluk, Hosur Road, Bangalore, Karnataka 560099 India
| | - Srirangapatna Varadaraj Srikrishna
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, 258/A, Narayana Hrudayalaya, Bommasandra Industrial Area, Anekal Taluk, Hosur Road, Bangalore, Karnataka 560099 India
| | - Kasturi Srikanth
- Department of Cardiothoracic Surgery, Narayana Institute of Cardiac Sciences, 258/A, Narayana Hrudayalaya, Bommasandra Industrial Area, Anekal Taluk, Hosur Road, Bangalore, Karnataka 560099 India
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Kao CN, Chou SH, Huang CL, Lin CH, Chiang HH, Lee JY, Li HP, Chang PC, Liu YW. Salvage surgery using simultaneous clamshell thoracotomy with median sternotomy for mediastinal growing teratoma syndrome. Thorac Cancer 2020; 11:785-788. [PMID: 31925930 PMCID: PMC7049485 DOI: 10.1111/1759-7714.13297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/01/2022] Open
Abstract
This report describes the case of a 17‐year‐old man who developed mediastinal growing teratoma syndrome following two cycles of chemotherapy, after an initial diagnosis of primary mediastinal nonseminomatous germ cell tumor. The large, rapidly‐growing mediastinal tumor was completely resected in conjunction with right pneumonectomy, using simultaneous clamshell thoracotomy and median sternotomy. The salvage surgery with perioperative management involved in mediastinal growing teratoma syndrome is presented here. Key points
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Affiliation(s)
- Chieh-Ni Kao
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shah-Hwa Chou
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Surgery, Pingtung Hospital, Ministry of Health and Welfare, Pingtung, Taiwan
| | - Chien-Lin Huang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hung Lin
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Hsing Chiang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jui-Ying Lee
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsien-Pin Li
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Chih Chang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Wei Liu
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Segalini E, Di Donato L, Birindelli A, Piccinini A, Casati A, Coniglio C, Di Saverio S, Tugnoli G. Outcomes and indications for emergency thoracotomy after adoption of a more liberal policy in a western European level 1 trauma centre: 8-year experience. Updates Surg 2018; 71:121-127. [PMID: 30588565 PMCID: PMC6450838 DOI: 10.1007/s13304-018-0607-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 11/11/2018] [Indexed: 12/03/2022]
Abstract
The role of emergency thoracotomy (ET) in blunt trauma is still a matter of debate and in Europe only a small number of studies have been published. We report our experience about ET both in penetrating and blunt trauma, discussing indications, outcomes and proposing an algorithm for patient selection. We retrospectively analysed patients who underwent ET at Maggiore Hospital Trauma Center over two periods: from January 1st, 2010 to December 31st, 2012, and from January 1st, 2013 to May 31st, 2017. Demographic and clinical data, mechanism of injury, Injury Severity Score, site of injury, time of witnessed cardiac arrest, presence/absence of signs of life, length of stay were considered, as well as survival rate and neurological outcome. 27 ETs were performed: 21 after blunt trauma and 6 after penetrating trauma. Motor vehicle accident was the main mechanism of injury, followed by fall from height. The mean age was 40.5 years and the median Injury Severity Score was of 40. The most frequent injury was cardiac tamponade. The overall survival rate was 10% during the first period and 23.5% during the second period, after the adoption of a more liberal policy. No long-term neurological sequelae were reported. The outcomes of ET in trauma patient, either after penetrating or blunt trauma, are poor but not negligible. To date, only small series of ET from European trauma centres have been published, although larger series are available from USA and South Africa. However, in selected patients, all efforts must be made for the patient’s survival; the possibility of organ donation should be taken into consideration as well.
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Affiliation(s)
- Edoardo Segalini
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Luca Di Donato
- General and Emergency Surgery, Arcispedale S. Maria Nuova Hospital, Reggio Emilia, Italy
| | - Arianna Birindelli
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Alice Piccinini
- Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Alberto Casati
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Carlo Coniglio
- Trauma Intensive Care Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Salomone Di Saverio
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy.
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Gregorio Tugnoli
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
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Toda M, Izumi N, Tsukioka T, Komatsu H, Okada S, Hara K, Ito R, Shibata T, Nishiyama N. Huge mediastinal liposarcoma resected by clamshell thoracotomy: a case report. Surg Case Rep 2017; 3:16. [PMID: 28105611 PMCID: PMC5247384 DOI: 10.1186/s40792-017-0291-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/14/2017] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Liposarcoma is the single most common soft tissue sarcoma. Because mediastinal liposarcomas often grow rapidly and frequently recur locally despite adjuvant chemotherapy and radiotherapy, they require complete excision. Therefore, the feasibility of achieving complete surgical excision must be carefully considered. We here report a case of a huge mediastinal liposarcoma resected via clamshell thoracotomy. CASE PRESENTATION A 64-year-old man presented with dyspnea on effort. Cardiomegaly had been diagnosed 6 years previously, but had been left untreated. A computed tomography scan showed a huge (36 cm diameter) anterior mediastinal tumor expanding into the pleural cavities bilaterally. The tumor comprised mostly fatty tissue but contained two solid areas. Echo-guided needle biopsies were performed and a diagnosis of an atypical lipomatous tumor was established by pathological examination of the biopsy samples. Surgical resection was performed via a clamshell incision, enabling en bloc resection of this huge tumor. Although there was no invasion of surrounding organs, the left brachiocephalic vein was resected because it was circumferentially surrounded by tumor and could not be preserved. The tumor weighed 3500 g. Pathologic examination of the resected tumor resulted in a diagnosis of a biphasic tumor comprising dedifferentiated liposarcoma and non-adipocytic sarcoma with necrotic areas. The patient remains free of recurrent tumor 20 months postoperatively. CONCLUSIONS Clamshell incision provides an excellent surgical field and can be performed safely in patients with huge mediastinal liposarcomas.
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Affiliation(s)
- Michihito Toda
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Nobuhiro Izumi
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Takuma Tsukioka
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hiroaki Komatsu
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Satoshi Okada
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kantaro Hara
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ryuichi Ito
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Toshihiko Shibata
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Noritoshi Nishiyama
- Department of Thoracic Surgery, Osaka City University Medical School, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
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Puchwein P, Sommerauer F, Clement HG, Matzi V, Tesch NP, Hallmann B, Harris T, Rigaud M. Clamshell thoracotomy and open heart massage--A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study. Injury 2015; 46:1738-42. [PMID: 26068645 DOI: 10.1016/j.injury.2015.05.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/29/2015] [Accepted: 05/19/2015] [Indexed: 02/02/2023]
Abstract
AIMS Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. METHODS We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. RESULTS The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. CONCLUSION Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.
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Affiliation(s)
- Paul Puchwein
- Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Florian Sommerauer
- Medical University of Graz, Department for Traumatology, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Hans G Clement
- Unfallkrankenhaus Graz, Göstinger Straße 24 8020 Graz, Austria
| | - Veronika Matzi
- Unfallkrankenhaus Graz, Göstinger Straße 24 8020 Graz, Austria
| | - Norbert P Tesch
- Medical University of Graz, Institute of Anatomy, Harrachgasse 21, 8010 Graz, Austria
| | - Barbara Hallmann
- Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria
| | - Tim Harris
- Queen Mary University of London and Barts Health NHS Trust, Whitechapel, London, UK
| | - Marcel Rigaud
- Medical University of Graz, Department for Anaesthesiology and Intensive Care, Auenbruggerplatz 29, 8036 Graz, Austria
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