Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury

A prospective trial of videothoracoscopy was conducted at an urban trauma center between February 1992 and February 1993 to determine the efficiency of this less invasive method of evaluation and treatment. Twenty-four consecutive patients with chest trauma (penetrating, n = 22; blunt, n = 2) were examined thoracoscopically for clotted hemothorax that otherwise would have been treated with thoracotomy (n = 9), suspected diaphragmatic injury (n = 10), and continued bleeding (n = 5). To ensure maximal exposure, general anesthesia with a double-lumen endotracheal tube was used in each patient. Clotted hemothorax was successfully evacuated in eight of nine patients (89%). Diaphragmatic laceration was suspected in 10 patients (2 abnormal chest radiographs, 8 proximity penetrating wounds) and confirmed thoracoscopically in 5. In four patients, diaphragmatic lacerations were successfully repaired with thoracoscopic techniques. Five patients underwent thoracoscopy for continued hemorrhage (greater than 1,500 mL per 24 hours) after tube thoracostomy. Intercostal artery injury was confirmed in all patients, and diathermy provided hemostasis in three patients without thoracotomy. No complications occurred. These data suggest the following: (1) Videothoracoscopy is an accurate, safe, and minimally invasive method for the assessment of diaphragmatic injuries, control of continued chest wall bleeding, and early evacuation of clotted hemothorax. (2) This technique should be used more frequently in patients with thoracic trauma. (3) Technical advances may expand the therapeutic role of thoracoscopy.     

Malformations of neocortical development: magnetic resonance imaging correlates

BACKGROUND: The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients. METHODS: The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2). RESULTS: The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient. CONCLUSIONS: Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.     

Operative videothoracoscopy in the surgical treatment of penetrating firearms wounds of the chest

We prospectively analyzed our experience with operative videothoracoscopy (OVT) performed in a field military hospital in cases of penetrating firearms wounds of the thorax (PFAWT) sustained in Chechnya. From February to April 1996, we treated 206 wounded patients, of whom 37 (18.0%) had sustained chest injuries. PFAWT were present in 23 soldiers, accounting for 62.2% of all chest injuries. Twelve injuries were confined to the thorax, eight patients had associated injuries, and three soldiers had thoracoabdominal injuries. Nineteen patients had pleural drainage performed during medical evacuation. The thoracic injuries were right-sided (17), involved bullets or shell splinters (23); were through and through (16), represented solitary wounds (19), and were associated with internal organ injuries (21). Fifteen patients had indications for OVT when they were delivered from the battle-field 1.5 to 22 hours after injury. All patients manifested signs of hemorrhagic shock and hemodynamic instability. Indications for OVT were ongoing intrapleural bleeding (6), clotted hemothorax (6), or marked air leakage (3) preventing lung inflation with the OP-02 apparatus (field modification). OVT revealed 12 lung wounds, nine of which were multiple wounds, pleural bleeding in 6 patients, clotted hemothorax in 11 patients, and foreign bodies in 5 patients. Two patients underwent thoracotomy, one for suspicion of heart injury and the second because we could not adequately visualize and control bleeding revealed at OVT to be from the intercostal artery in the left costovertebral angle. Eight of 23 patients had no indication for operative videothoracoscopy and were managed with continued pleural aspiration and drug therapy. Wedge resection of the lung using an Endo-GIA-30 stapler was necessary in two patients because of parenchymal destruction and bleeding. Evacuation of clotted blood by fragmentation and aspiration was satisfactory in all cases. Satisfactory manual suturing of selected lung injuries was obtained largely with intracorporeal knot tying. The duration of the procedures ranged from 40 to 90 minutes. No morbidity nor mortality was encountered in patients undergoing OVT. Postoperative pain was minimized by using OVT placement of catheters in the chest wall soft tissue with local administration of 2% Trimecain. Patients were able to stand in 10 to 12 hours and to walk by the end of the first postoperative day. All patients who underwent OVT were evacuated without drains by the third or fourth postoperative day, all tolerating sitting and standing positions. We conclude that early OVT in the military field hospital for continued bleeding, clotted hemothorax, and continued major air leakage has several advantages in military patients with PFAWT: early definition and management of organ injury; identification and control of bleeding in most instances; earlier and more accurate assessment for thoracotomy; vigorous lavage and removal of projectiles such as bone fragments and evacuation of clotted hemothorax; early debridement with suture closure of the thoracic wall canal; and minimal postoperative pain with dramatically reduced suppurative sequelae and bronchopleural fistulae.     

Indications for thoracotomy following penetrating thoracic injury

The treatment of penetrating thoracic injuries has been reviewed in both civilian and military series. Although most surgeons agree that closed that closed thoracostomy drainage is the initial treatment of choice, the timing of early thoracotomy and perhaps cardiorrhaphy upon patients with penetrating thoracic injuries remains controversial. The purpose of this study was to determine which patients will require immediate thoractomy or cardiorrhaphy following penetrating chest injury. Over a two-year period 190 patients with penetrating thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Seventy-nine patients required laparotomy for associated intra-abdominal injuries. The mortality rate was related to exsanguinating hemorrhage or postoperative intra-abdominal sepsis. Cardiopulmonary complications were rare in the absence of intra-abdominal sepsis and could not be attributed to the thoracic injury or thoracotomy. Indications for immediate cardiorrhaphy or thoracotomy are: 1) location of the entrance wound (70% in upper mediastinum); 2) blood pressure on admission less than 90; 3) initial thoracostomy blood loss greater than 800 cc; 4) radiographic evidence of retained hemothorax; and/or 5) clinical evidence of pericardial tamponade.     

Pediatric penetrating thoracic trauma: a five-year experience

Penetrating thoracic trauma is managed nonoperatively in 85% of adult patients. We hypothesized that similar trauma in children would lead to proportionately more vital tissue damage and a higher rate of operative intervention. The pediatric penetrating thoracic trauma experience of a level one trauma center was analyzed over a five-year period. Data reviewed included circumstances of injury, Pediatric Trauma Score (PTS), interventions performed, and outcome. Of 61 children with thoracic trauma, 13 had penetrating injuries. Of these 13, seven were unintentional (five from firearms); the rest were caused by assaults. Seven patients (54%) underwent thoracotomy or laparotomy. All five patients with a PTS < 8 underwent surgical intervention, whereas only two of the eight patients with a PTS > or = 8 needed surgery (P < 0.05). There was one death. We reached the following conclusions: 1) Children with penetrating thoracic trauma are more likely to require surgical intervention than adults. 2) Penetrating thoracic trauma in children should elicit a thorough search for operative lesions. 3) About half these injuries are unintentional, and thus potentially preventable.     

The operative videothoracosopy in rendering emergency surgical care in penetrating gunshot chest wounds

The modern doctrine of military surgery is based on the concept of maximal and, if possible, simultaneous surgical aid to the wounded in the shortest period of time after the injury. It could be achieved by approximation of specialized surgical section to the zone of fighting and improvement of medical evaluation. These are conditions for applicability of modern methods of treatment and for perfecting of surgical strategies to the wounded, such as videothoracoscopy. To report the experience of the usage of videothoracoscopy in the treatment of the wounded with penetrating gunshot wounds of chest (PFAWT) in military hospital. 23 patients with PFWAT was administer surgical therapy: 19 patients had pleural draining at previous stages of medical evacuation, 4 patients were delivered directly from the battle Geld 1.5 hours after the injury. 11 patients with pleural drains and 4 patients, delivered from battle Geld, had indications for videothoracoscopy. These indications included ongoing intrapleural bleeding, clotted hemothorax and prolonged leakage of the air through the drain. Suturing of the lung wounds was performed by Endo-GIA-30 stapler. If it was impossible, manual suture EndoStitch USSC was used. In 2 cases was performed wedge-like resection by EndoGIA-30. The bleeding from the thoracic wall wounds was controlled by electrocautery. The clotted hemothorax was removed by fragmentation with EndoBabcock, washing out and aspiration through large diameter tubes. The duration of the procedure ranged from 40 to 90 minutes. None had suppurative complications. All patients was survived. The mean duration of inpatient period was 20 days, rehabilitation period-14 days.     

Videothoracoscopic surgery

Although thoracoscopy has been used for diagnostic and minor therapeutic procedures for many years, there have been few reports of its use in performing major intrathoracic procedures which have traditionally required formal thoracotomy. We report our initial experience in this field. Fifty patients (M:F = 1.63:1, mean +/- SD age = 41.8 +/- 20.4 years, range = 14-80) underwent 54 endoscopic intrathoracic operations. The procedures carried out included wedge excision of solid pulmonary mass (10), pleurectomy (25), lung biopsy (14), and miscellaneous procedures (5). Under general anaesthesia a laparoscope attached to a video monitor was introduced into the chest. One or two additional stab incisions were made as needed for the introduction of standard surgical or endoscopic instruments and staplers. There were no deaths. One patient developed a second pneumothorax 7 days after endoscopic pleurectomy, necessitating open pleurodesis. All patients were discharged home between 2 and 11 days after surgery (mean +/- SD = 3.8 +/- 2.0 days). Endoscopic thoracic surgery is a safe and useful technique for certain cases. It merits further investigation and assessment.     

Complications of thoracoscopy

BACKGROUND: The revolution in video technology has led to the acceptance of thoracoscopy as an important tool in thoracic surgery. METHODS: A review of all patients undergoing thoracoscopy at the University of Maryland between November 1991 and March 1995 was performed to identify the incidence of intraoperative and postoperative complications. In addition, the role of computed tomography for predicting intraoperative complications was analyzed. RESULTS: Three hundred forty-eight procedures were performed in 321 patients. Twenty-seven patients required conversion to thoracotomy for various indications. In 12 patients further resection was required after frozen section diagnosis confirmed lung carcinoma. Six patients were opened due to adhesions. Two patients were opened due to inability to find the lesion (this represents 1.6% of all solitary pulmonary nodules). Three cases were converted to thoracotomy for lesions that were too large to remove (representing 2.5% of all solitary pulmonary nodules resected). Two patients required conversion to thoracotomy because of inability to obtain one-lung ventilation. One case required a limited thoracotomy for a lost needle used for needle localization of a solitary intraparenchymal nodule, and 1 patient had emergent exploration for bleeding. Early postoperative complications developed in 10 patients. There were two explorations in the immediate postoperative period for bleeding. Prolonged air leak occurred in 3 patients, empyema in 2, and recurrent pneumothorax, pulmonary edema, and pneumonia in 1 patient each. Computed tomography failed to diagnose adhesions in the majority of patients requiring conversion to thoracotomy. CONCLUSIONS: Thoracoscopy is a safe and effective procedure with low intraoperative and postoperative complication rates.     

Posttraumatic empyema thoracis: a 24-year experience at a major trauma center

The purpose of this paper is to review the outcome of patients with posttraumatic empyema thoracis. Between April 1972 and March 1996, the Division of Cardiothoracic Surgery at the King-Drew Medical Center managed or was consulted on 5,474 trauma patients (4,584 patients with penetrating injuries and 890 with blunt injuries) who were admitted emergently for thoracic and thoracoabdominal injuries and who underwent tube thoracostomy. Patients were not given routine prophylactic antibiotics merely because they had a chest tube placed. Based on our previous reports on thoracic trauma, our criteria for empiric antibiotic administration included (1) emergent or urgent thoracotomy, (2) soft-tissue destruction of the chest wall by shotgun injuries, (3) lung contusion with hemoptysis, (4) associated abdominal trauma requiring exploratory laparotomy, or (5) associated open long-bone fractures. Eighty-seven of these 5,474 patients developed posttraumatic empyema thoracis, for an incidence of 1.6%. These 87 patients were treated with tube thoracostomy, image-guided catheter drainage, or open thoracotomy with decortication. Seventy-nine of 87 patients (91%) were cured without conversion to open thoracostomy. Four patients required conversion to open thoracostomy, and there were three deaths. Even though a majority of our patients required decortication, successful management of posttraumatic empyema thoracis also was achieved with closed-tube thoracostomy or image-guided catheter drainage based on clinical and radiographic findings with appropriate patient selection. When thoracic empyema did occur in our group, Staphylococcus aureus was the most common microbe isolated, followed by anaerobic bacteria. In correlating microbiologic data with outcomes, S. aureus, especially methicillin-resistant S. aureus, was the most frequent cause of antibiotic failure. Because of the low incidence of posttraumatic empyema thoracis, we do not recommend routine antibiotic prophylaxis for all trauma patients who undergo closed-tube thoracostomy. A review of the role of tube thoracostomy, intrapleural fibrinolytic therapy, image-guided catheter drainage, video-assisted thoracoscopy, and open thoracotomy for the management of thoracic empyema is provided.     

Successful treatment of exsanguinating aortic injury from a fractured rib

A 57-year-old man presented in shock after a 15-foot fall from a ladder. A massive left hemothorax was present. He underwent prompt thoracotomy and was found to have a penetrating injury of the descending thoracic aorta caused by a fractured rib. Successful management of this type of aortic injury has not been previously reported.     

Resection of pulmonary nodules using video-assisted thoracic surgery. The Thorax Group

BACKGROUND: The aim of this study was to assess the experience with video-assisted thoracic surgery for the resection of pulmonary nodules. METHODS: This voluntary registry (20 centers) included 388 patients with either benign (n = 171) or malignant (n = 217) pulmonary nodules. Pulmonary nodules were located using computed tomography scan-guided injection of methylene blue (59 patients) and hook wire technique (17 patients). RESULTS: Video-assisted thoracic surgery was converted into thoracotomy in 67 patients (17%) because of technical-emergency in 4, inability to complete resection in 33, and the need to perform lobectomy for cancer through thoracotomy in 30. In other patients, video-assisted thoracic surgery allowed wedge resection in 300 cases and lobectomy in 21 cases. No intraoperative and two postoperative deaths (0.56%) occurred. The complication rate was 8% (n = 31). Mean durations of chest tube placement and hospital stay were 3.3 days (range, 1 to 20 days) and 6 days (range, 1 to 25 days), respectively. Video-assisted thoracic surgery was judged by the surgeon to be a diagnostic procedure 226 times (58%) and a therapeutic procedure 162 times (42%). CONCLUSION: Video-assisted thoracic surgery appears to be safe and remains mainly a diagnostic procedure for malignant tumors.     

Porous diaphragm syndromes

Porous diaphragm syndromes are a group of seemingly disparate clinical symptom complexes involving a wide variety of unrelated medical specialties. However, they are linked by a common anatomical feature, a defect in the diaphragm. They usually present with thoracic symptomatology--pleural effusions, pneumothorax, hemothorax, empyema--mediated by this defect. Management of these syndromes utilizes principles of thoracic surgical practice including thoracotomy and thoracoscopy.     

Penetrating chest injuries in children: a review of 94 cases

Ninety-four children with penetrating chest injuries were treated at Dicle University School of Medicine during a 6-year period. The mean age was 11.51 +/- 3.31 years, and the male:female ratio was 5.25:1. Forty-five had stab wounds, 27 had high-velocity gunshot wounds, 13 had low-velocity gunshot wounds, seven had a bomb (shrapnel) injury, one had a shotgun wound, and one had a horse bite. Sixty patients had isolated thoracic injuries, and 34 had associated injuries. The most common thoracic injury was hemothorax (28), followed by hemopneumothorax (25). Tube thoracostomy alone was sufficient in 79.8% of the patients (75 of 94). Thoracotomy was performed in 4.25% (4 of 94). In two of the five observed patients, delayed hemothorax developed. The mean duration of hospitalization was 5.13 +/- 1.93 days. The mean Injury Severity Score was 14.71 +/- 8.62. Prophylactic antibiotics were used in all patients. The morbidity rate was 8.51% (8 of 94). Only one death occurred after cervical tracheal repair. The study suggests that the majority of penetrating chest injuries in children can be treated successfully by tube thoracostomy alone or in conjunction with expectant observation.     

Current trends in in the treatment of spontaneous pneumothorax

In agreement with a number of published reports we state that video thoracoscopy is the best means for pnx classification (Vanderschueren RJA) and for the choice of its treatment. Video thoracoscopy and recent innovations in video-assisted thoracic surgery (VATS), together produce a significant improvement in the results. Between February 1992 and September 1994, we treated 143 pnx in 133 patients, 118 males, mean age 34 years (range 14-82); 5 of which undergoing a bilateral treatment and another 5 having to undergo a retreatment. On the basis of the endoscopic classification (Vanderschueren RJA), 26.1% of the cases fell into category I and 67.4% into the higher category, 6.5% presented enlarged bullous emphysema (GBE). Twenty-seven patients (20.3%), classified as category I at the first appearance of pnx, were treated by means of a chest tube thoracostomy. The remaining patients underwent surgical treatment: 106 treatments by VATS (74.1%) and 10 (7%) by an axillary thoracotomy. By VATS we performed: 77 ligature/resections of bullous lesions, 9 resections of pulmonary apex, 9 adhesiolysis, 7 GBE treatment by the "spaghetti technique", 2 coagulations of blebs, 1 suture and 1 parenchymal laceration repair by clips. No patients treated by a chest tube thoracostomy or who underwent thoracotomy presented recurrence at the follow-up (mean 33 months, range 15-46). We had a single complication (0.9%), 2 treatment conversions (1.9%) and in 3 patients (2.8%) a thoracotomy was necessary four days later. In thoracotomy we performed 5 resections of bullous lesions and 2 "capitonages" were effected in those patients treated in the first instance; 2 parenchyma tear repairs and 1 lobectomy in those patients treated after the failure of VATS.     

Embolization therapy as an alternative to thoracotomy in vascular injuries of the chest wall

Hemothorax and persistent thoracic bleeding is frequently an indication for thoracotomy after trauma. Unfortunately, the source of the hemorrhage is often not identified. Presently, selective arteriography and transcatheter embolization (SATE) offers a good and safe alternative to localize and control hemorrhage from arterial injuries in selected patients. The records of eight patients who underwent SATE were reviewed. There were six blunt and two penetrating chest injuries. Four patients had significant preexisting medical comorbidities. Three patients with blunt injuries had undergone exploratory thoracotomy, but continued to bleed postoperatively. In three patients, angiography was indicated for associated thoracic and pelvic injuries, and five patients had SATE specifically due to thoracic hemorrhage. In all patients, SATE was effective to diagnose and control the hemorrhage. There were no complications related to the SATE procedure. Two patients died secondary to severe cerebral injuries. Given hemodynamic stability, SATE can be considered in patients who have already had a thoracotomy, have significant associated medical conditions, or those in need of other angiographic studies. Careful technique and a readiness to abandon SATE in unstable patients or when a suitable catheter position cannot be achieved are important technical points.     

Video-assisted thoracoscopic surgery to the upper thoracic spine

BACKGROUND: The standard open technique for exposure of the upper thoracic spine, T1-T4, usually requires a difficult thoracotomy. From November 1, 1995 to June 30, 1997, eight patients underwent video-assisted thoracoscopic spinal surgery in our institute to treat their upper thoracic spinal lesions endoscopically. METHODS: A new approach, the so-called "extended manipulating channel method," was used in this series that allows the combined use of video-assisted thoracoscopy and conventional spinal instruments to enter the chest cavity freely for the procedures. Patients' ages ranged from 44 to 89 years (average, 60 years). Definitive diagnoses included two pyogenic spondylitis and six spinal metastases. Five patients presented initially with myelopathy. RESULTS: There were no deaths or neurologic injuries associated with this technique. The mean surgical time was 3.1 h. The mean duration of chest tube retention was 3.3 days. The mean total blood loss was 1,038 ml, and two patients had a blood loss of more than 2,000 ml owing to bleeding from epidural veins or raw osseous surfaces. Complications included one superficial wound infection and one subcutaneous emphysema that resolved spontaneously. In this series, there was no need of conversion to open thoracotomy for the patients. CONCLUSIONS: The thoracoscopy-assisted spinal technique using the extended manipulating channels, usually 2.5-3.5 cm, allows variable instrument angulations for manipulation. The mean surgical time (3.1 h) was considered no longer than for an open technique for the equivalent anterior procedure. Such an approach can achieve less procedure-related trauma and has proved to be a good alternative to other treatment modalities.     

Expression of inducible nitric oxide synthase in the brains of scrapie-infected mice

Thoracic trauma in the elderly population constitutes a major challenge for both thoracic and trauma surgeons as their presentation and outcomes differ from the adult population in addition to their high morbidity and mortality. One hundred and one patients, 60 years of age or older, with thoracic trauma were treated at Dicle University School of Medicine during a 6-year period. Eighty-five per cent were male and 15% were female with a mean age of 64.5 years. The cause of thoracic injury was blunt in 77.2% and penetrating in 22.8% of the patients. Sixty-two patients (61.4%) had isolated thoracic injuries. The median Injury Severity Score (ISS) was 23. The morbidity rate was 23.8%. The mortality rate was 16.8%. Seven of 10 patients (70%) who had an ISS greater than 25 died, whereas six of 24 (25%) patients with an ISS between 17 and 25, and four of 67 (5.9%) patients with an ISS less than 16 died. In the elderly the morbidity and mortality rates were higher for blunt trauma compared with penetrating trauma. For ISS greater than 25 the mortality rate was 71.4% for blunt and 66.6% for penetrating trauma. As the morbidity and mortality rate are significantly higher in the elderly patients the approach to these patients should include recognition of their high risk for morbidity and mortality, especially for those who had an ISS greater than 25.     

Future education: what do nurse executives need?

A small number of trauma patients with penetrating thoracic trauma will require formal pulmonary resections to repair severe injuries or control massive haemorrhage. Although previous reports on this subject have addressed the management of these injuries in battle conditions, civilian experience with this type of chest injury is limited. In a 3-year period, 259 patients underwent urgent thoracotomies for penetrating thoracic trauma. We retrospectively reviewed 43 patients who underwent lobectomies or pneumonectomies to control bleeding (93%) or bronchial injuries (7%). Handguns were the aetiologic agent in 41 patients (95%). The most common complication, pneumonia, was seen in 21 patients (87%). Fifteen patients (62%) developed respiratory failure. The complications of wound infection, post-operative haemorrhage and empyema were seen in equal frequency in four patients (16%). Two patients (8%) developed bronchopleural fistulas. Nine pneumonectomies and 34 lobectomies were performed with mortality rates of 66% and 38%, respectively (overall mortality, 44%). Ten (53%) deaths occurred in the operating room, late deaths (2-15 days) were secondary to sepsis and multiple organ dysfunction syndrome (MODS). Currently, the management of patients with devastating thoracic injuries to the thoracic cavity is divided into two stages. First, initial resuscitation with rapid surgery to control major bleeding, cardiac tamponade, tracheal disruptions and potentially lethal air embolism is indicated. Once the life-threatening conditions have been resolved, definitive surgical procedures are performed to repair injuries to any of the thoracic structures.     

Thoracoscopic major pulmonary resection--pro and con

The first reports of thoracoscopic video-assisted procedures are from 1993. The main reason for this new techniques was that they allow the performance of standard thoracic surgical procedures in a less invasive ways. The operation trauma is minimalised that could be a cause not only of postoperative pain but often also of chronic future problems. The other advantages are the shortened hospitalisation time and earlier end of disablement. On the other hand there are many objective arguments against here. Firstly, the operative technique is not standardised and thoracoscopic lobectomy and pneumonectomy are performed by many modified methods. No regular randomised studies are available that could confirm the positive contribution of thoracoscopy in these cases. It is possible to perform classic thoracotomy by very careful way saving muscles and contemporary observing the requirement of safe operation and to attain the maximally possible result. Resuming information from written and verbal reports in last 3 years we have necessary the impression that the main reason for thoracoscopic reactions was to demonstrate the technical feasibility of this operation which is entirely insufficient reason for acceptance of this technique. Authors suggest that thoracoscopy is in experienced hands and adequately equipped workplaces an accurate and safe method for the diagnosis and in some cases also for therapy of hemodynamic stabile patients with thoracic trauma.     

Biloma and biliary fistula associated with hepatorrhaphy for liver injury

BACKGROUND/AIMS: To review our experience in managing post-hepatorrhaphy complications in liver trauma. MATERIALS AND METHODS: During the period of 1986-1994, 6250 trauma patients were admitted to the Accident & Emergency Unit of the University Hospital Kuala Lumpur. The medical records were reviewed. There were 175 patients with liver trauma requiring hepatorrhaphy. The major post-operative complications (biloma and biliary fistula) were noted. We reviewed and discussed the various management of these biliary complications. RESULTS: Eleven patients developed either a biloma, biliary fistula or both. Patients age ranged from 15 to 40 years with a mean ISS of 23. Seven patients suffered penetrating injury and 4 were victims of blunt trauma. The right lobe was injured in 10 patients, with 1 patient sustaining left lobe injury. All liver injuries were either grade 3 (7 patients) or grade 4 (4 patients). No patient sustained extrahepatic biliary tract injury. Biloma and fistulas were diagnosed 14-30 days post-injury (mean 24 days) by CT or HIDA scans. All were managed by CT-guided percutaneous drainage. One patient also required percutaneous transhepatic cholangiography with biliary stent placement due to bile-stained ascites. Fistulas persisted from 5-120 days (mean 44 days). No patient required further operative intervention all fistula closed spontaneously without complication. CONCLUSION: Uncomplicated biliary fistula post-hepatectomy for liver trauma can be treated with percutaneous drainage.