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Background Practice guidelines for the appropriate use of emergency department thoracotomy (EDT) according to current national resuscitative guidelines have been developed by the American College of Surgeons Committee on Trauma (ACS-COT) and published. At an urban level I trauma center we analyzed how closely these guidelines were followed and their ability to predict mortality. Methods Between January 2003 and July 2010, 120 patients with penetrating thoracic trauma underwent EDT at Mount Sinai Hospital (MSH). Patients were separated based on adherence (group 1, n=70) and nonadherence (group 2, n=50) to current resuscitative guidelines, and group survival rates were determined. These 2 groups were analyzed based on outcome to determine the effect of a strict policy of adherence on survival. Results Of EDTs performed during the study period, 41.7% (50/120) were considered outside current guidelines. Patients in group 2 were less likely to have traditional predictors of survival. There were 6 survivors in group 1 (8.7%), all of whom were neurologically intact; there were no neurologically intact survivors in group 2 ( p = 0.04). The presence of a thoracic surgeon in the operating room (OR) was associated with increased survival (p = 0.039). Conclusions A policy of strict adherence to EDT guidelines based on current national guidelines would have accounted for all potential survivors while avoiding the harmful exposure of health care personnel to blood-borne pathogens and the futile use of resources for trauma victims unable to benefit from them. Cardiothoracic surgeons should be familiar with current EDT guidelines because they are often asked to contribute their operative skills for those patients who survive to reach the OR.

Jay Ankeney, the 16th President of The Society of Thoracic Surgeons, was an early pioneer in adult and pediatric cardiac operations, a prescient advocate of off-bypass coronary revascularization, and a strong champion of cardiothoracic recertification. He was among the first to endorse the need to provide practicing cardiothoracic surgeons the means for self-assessment and improvement. He led the development of Coordinating Committee for Continuing Education in Thoracic Surgery and inaugurated the self-education/self assessment syllabus for this purpose. Under his leadership he persuaded the vast majority of cardiothoracic surgeons to embrace recertification and by this means provide reassurance and accountability to their patients.

Primary neuroendocrine tumors of the thymus are highly aggressive tumors that rarely occur. A little more than 200 cases have been reported, many of which were single case reports. Only a few articles contained modest series from single centers for analysis. A review of 157 cases collected from the major series reported to-date show a clinical pattern with male preponderance (male:female ratio, 3:1) and a mean age of 54 years. Most patients presented with symptoms and signs of local compression. Almost 50% of these tumors were functionally active and were associated with endocrinopathies. Several histologic variants have been described, all with similar ultrastructural features. The biologic behavior of these tumors shows a direct relation to the degree of differentiation. Whenever possible, surgical resection is the treatment of choice as adjuvant therapy is controversial and has been used with variable success. Potential therapies exploit the presence of somatostatin receptors on a variety of these tumors. Use of radiolabeled Octreotide for radionuclide therapy has yielded tumor inhibition in animal models and may have clinical application. Fifty-one percent of the patients survived 3 years, 27% survived 5 years, and less than 10% survived beyond 10 years. Histologic grade, tumor extension, and early detection are the most important factors affecting survival. Other prognostic factors that impact outcome include presence of endocrinopathy, incomplete resectability, nodal status, and presence of distant metastasis.

Background The objective of this study was to review the clinical experience of temporarily placing an endoesophageal silicone salivary bypass stent and its value in managing patients with life-threatening esophageal disruptions. Methods Clinical records of patients undergoing placement of silicone Montgomery salivary bypass stents from June 1998 to September 2007 were reviewed. Seventeen patients had a proven esophageal disruption in the absence of malignancy and with life-threatening sepsis refractory to conventional management. Underlying conditions were iatrogenic trauma from prior pulmonary surgery (4 patients), significant anastomotic leaks after an esophagogastrectomy (4 patients), delayed presentation (> 24 hours) of a perforated esophagus (4 patients), leak after esophageal surgery (3 patients), and esophagobronchial fistula secondary to inflammation and infection (2 patients). Stents were placed without securing, were sutured in place to the esophageal wall at the time of thoracotomy, or were secured by bringing holding sutures through the nostrils and tied over the bridge of the nose. Results In all cases, placement of the esophageal stent led to prompt improvement of the leak and, within a week, improvement of the sepsis. Supportive measures were continued after placement of the stent. Sixteen patients overcame the sepsis with ultimate healing of the esophageal disruption (13 patients) or maturation of the perforation into a chronic fistula (3 patients). Endoscopic stent removal was performed 2 to 16 weeks after placement. No patient had a stricture develop at the disruption site. One patient died of ruptured thoracic aorta. Conclusions Silicone salivary bypass stents serve as an effective way of diverting and excluding the oral-alimentary stream, thereby providing optimal conditions for sepsis control. They are a useful adjunct in the management of complex esophageal conditions.

An unusual case of a penetrating intracardiac injury is described in a 16-year-old boy who presented with a retained 14-cm segment of an ice pick that went unnoticed by the patient for 4 days. The ice pick had lacerated the anterior papillary muscle of the left ventricle causing avulsion of its tip and prolapse of the anterior leaflet of the mitral valve resulting in severe mitral regurgitation. The urgency for surgical correction of the traumatic mitral valve injury at the time of extraction of the intracardiac foreign body through a single-stage approach versus a two-stage approach is discussed.

Background . The most common indication for reoperation in patients with a bioprosthetic valve is primary tissue failure. Explantation of the bioprosthesis is time consuming, and for a mitral valve, may be complicated by cardiac rupture at the atrioventricular junction or the posterior left ventricular wall where a strut is imbedded, injury to the circumflex artery, and late perivalvular leak; for an aortic valve, annular disruption and perivalvular leak may complicate explantation. A new approach to simplify these procedures and avoid these complications, by excising only the bioprosthetic tissue and attaching a bileaflet mechanical valve to the intact stent, was developed in 1991 and was evaluated over a 9-year period in 50 patients who had had one (34), two (10), three (4), or four (2) previous open cardiac operations. Methods . Since 1991, we have replaced degenerated mitral bioprostheses in 34 patients (25 to 84 years of age; 12 male, 22 female) by preserving the stent and suturing a St. Jude or Carbomedics bileaflet valve to the atrial side of the bioprosthetic cuff; the mitral valve was exposed through a median sternotomy in 21 patients and through a right anterolateral thoracotomy in 13. Using a similar approach, starting in 1995, 16 additional patients (55 to 73 years of age; 11 male, 5 female) with degenerated aortic bioprostheses had the aortic valve replaced by excising the bioprosthetic tissue and amputating the struts, then suturing a Carbomedics valve to the aortic side of the bioprosthetic cuff. This allows the use of a bileaflet valve similar in size to the bioprosthesis with exact matching of the orifices. Results . Bypass time averaged 61 ± 14 minutes and aortic cross-clamp time 43 ± 12 minutes. There has been no operative mortality. Three late deaths occurred at 9, 37, and 58 months, and were not valve related. No gradients of hemodynamic significance have been detected on transesophageal echocardiographic follow-up. Conclusions . Leaving the bioprosthetic cuff intact eliminates the need for extensive dissection, thus shortening and simplifying the procedure and diminishing its attendant mortality and morbidity. This valve-on-valve approach also allows replacement of a degenerated bioprosthesis with a bileaflet valve of comparable size rather than a smaller one jammed into the orifice of the bioprosthetic stent, thus avoiding undue trauma to the bileaflet valve and maintaining excellent hemodynamic function.

Pharmacologic intervention to minimize postbypass bleeding and blood product transfusions has received increasing attention for both medical and economic reasons.Two hundred ten patients were entered into a double-blinded, prospective, randomized study to receive either 10 g of fibrinolytic inhibitor tranexamic acid before incision (n = 104) or 250 mL of placebo saline solution (n = 106). All subjects requiring cardiopulmonary bypass were deemed suitable, including those having first-time coronary bypass grafting, valve replacement, and reoperation.There were no statistically significant differences between the groups with respect to demographic or operative characteristics. The tranexamic acid group had a 48% reduction in 24-hour blood drainage (p0.001) and received 69% fewer total units of packed red blood cells, 83% fewer total units of plasma, and 75% fewer platelet transfusion units than controls. Only 13 of 104 tranexamic acid patients received blood products versus 33 of 106 controls (p0.001). The incidences of thrombotic complications, perioperative myocardial infarction, renal failure, and neurologic complications were not significantly different between the two groups. The tranexamic acid group had 0% mortality versus 1.9% for controls (not significant).Tranexamic acid is safe and effective in reducing blood loss and blood use in a wide variety of cardiac surgical patients.

Heterotopic implantation of the pulmonary venous confluence into the left atrial appendage during left lung transplantation is a reasonable alternative technique to reestablish venous drainage when exposure of the native left pulmonary veno-atrial connection may be problematic. We used this approach in a 39-year-old woman with chronic bronchiectasis who underwent bilateral sequential lung transplantation through a clam-shell approach. Dense hilar scarring and a small left atrial size made exposure of the native left pulmonary veno-atrial connection difficult.