Search

Background . Tracheobronchial injuries are encountered with increasing frequency because of improvements in prehospital care and early initiation of the Advanced Trauma Life Support protocol. We review our experience with these injuries with the hypothesis that the leading determinant of patient outcome is the time interval to diagnosis. Methods . Patients with tracheobronchial injury were identified from the registry of our level 1 trauma center during a 10-year period ending December 1997. Clinical presentation, diagnostic evaluation, surgical management, and outcome were reviewed. Results . Twenty patients with ten cervical tracheal injuries and ten intrathoracic tracheobronchial injuries were treated. The mechanism of injury involved blunt trauma in 11 and penetrating trauma in 9. All patients underwent surgical debridement and primary repair. Patients with isolated airway injuries were discharged home after a mean hospital stay of 6 days and had no early complications. Three patients had delayed diagnosis (> 24 hours), and all sustained complications including death (1 patient) and multiorgan system failure (2 patients). The overall mortality rate was 15%. Conclusions . Operative management of tracheobronchial injuries can be achieved with acceptable mortality. Independent of mechanism or anatomic location of injury, delay in diagnosis is the single most important factor influencing outcome. Early recognition of tracheobronchial injury and expedient institution of appropriate surgical intervention are essential in these potentially lethal injuries.

We analyzed the long-term results in 87 patients who had pectus deformities repaired at Fitzsimons Army Medical Center during the period 1953 to 1975. Seventy-one patients had operations for correction of pectus excavatum; 16 had pectus carinatum deformities repaired. A variety of surgical techniques was used in these patients. Our findings show that in excavatum deformities the best results were obtained by removing all deformed cartilage, mobilizing the sternum, using an anterior osteotomy, and stabilizing the chest with a metal strut (which was removed after one year). For carinatum defects, the Ravitch procedure has produced good results. We are encouraged to be more aggressive in advocating repair of the deformities, not only for cosmetic results but because the patients seem to feel healthier both physically and mentally after repair. For these reasons we advocate operation for pectus deformity at any age.

Two hundred fourteen patients underwent treatment for carcinoma of the esophagus between January, 1950, and July, 1978, with an over-all 5 year survival rate of 1.9%. Forty-six patients (21.5% of series) underwent esophageal resection with either esophagogastrostomy (37 patients) or colon interposition (nine patients). The operative mortality rate was 18.9% for the esophagogastrectomy group and 33% for the colon interposition patients. “Curative” resections resulted in a 14.3% 5 year survival rate. One hundred twenty-seven patients (59.3% of series) were treated by irradiation therapy, with a mean survival time of 9.6 months for patients receiving “curative” dosage (over 4,500 rads). There were no 5 year survivors in this group. Palliative procedures, such as feeding gastrostomy and palliative (less than 4,500 rads) irradiation therapy, contributed little to patient comfort or survival. We favor a palliative approach to the treatment of esophageal carcinoma and believe that, when possible, esophageal resection with esophagogastrostomy is the preferable form of therapy and offers an occasional cure.

In an effort to evaluate polytetrafluoroethylene (Gore-Tex) as a replacement for large veins, tubular grafts of the material were substituted for the precava in 33 mongrel dogs weighing 15 to 30 kg. Thirteen dogs had grafts 10 cm long by 12 mm wide with a 15-to 30 micron pore size; 15 dogs had grafts of the same length and width from 90-micron pore size material; and 5 dogs had grafts 5 cm long by 12 mm wide, of 90-micron pore size Gore-Tex. The effect of Gore-Tex tubes with and without spiral support and the differences in anatomical positions of the grafts were evaluated in terms of patency. Dogs were killed if a venogram showed occlusion of the graft. Twelve dogs survived 90 days; the longest survivor was killed at eleven months. At postmortem examination, the graft was patent but extremely narrow at the atrial end. Modification in the fabrication of Gore-Tex may eliminate factors contributing to graft failure; experiments longer than 90 days are necessary to evaluate Gore-Tex as a large vein replacement material. The 90-micron pore size material used in this experiment was unsuitable as a canine venous substitute.

Thirty patients in whom all aorta-coronary artery vein grafts became occluded within one year of operation, as demonstrated by cardiac catheterization, were evaluated for hypercoagulability. A total of 59 grafts were constructed in these patients. At operation, blood flows of 35 to 90 c.c. per minute were measured through the grafts. In 23 of the 30 patients, the blood was to be hypercoagulable, as evidenced by a low level of antithrombin III activity, high thrombin generation index, high factor VIII values, or high platelet adhesivity. Another group of 11 patients (total number of grafts, 23) had all grafts patent at cardiac catheterization. These patients had flows through the grafts ranging from 20 to 125 c.c. per minute. None of the patiens with patent grafts had hypercoagulable blood. The status of runoff was comparable between the patients with open grafts and those with occluded grafts.

One hundred patients were screened for hypercoagulability preoperatively and on the third, seventh, tenth, fourteenth, and twenty-first days postoperatively. Patients found to have hypercoagulability were treated with heparin, aspirin, and Coumadin. When the abnormality was present preoperatively, treatment was continued for the duration of the patient’s life. Those patients in whom abnormalities developed postoperatively were given anticoagulants until cardiac catheterization 6 months following their operation. Twenty-four of the 100 patients had no coagulation abnormalities preoperatively or postoperatively. Fifteen patients were found to have abnormality prior to operation. Their predominant abnormality was low antithrombin III activity. Sixty-one patients became hypercoagulable postoperatively. Predominant abnormality in this group of patients was increased thrombin generation and increased platelet adhesiveness. Evaluation of patients in this study group revealed a decrease in the incidence of pulmonary embolism, an increase in the patency of vein grafts, and the elimination of anticoagulant therapy in 24 percent of the patients.

An analysis of our experience with 48 patients having bronchiolar or alveolar cell carcinoma is reported. The remarkable biological variability of this peripheral tumor has important surgical implications. Basically, two dominant clinical presentations occur. In the less common diffuse or multinodular form, prolonged survival is infrequent regardless of the therapeutic approach. Often these patients die from respiratory compromise due to the tumor itself. In the more common localized or solitary form the prognosis for cure is good, approximating 47% or higher. Based on the material presented, lobectomy is the preferred method of surgical treatment. In patients manifesting multinodular disease, surgical resection rarely seems warranted. The concept of preserving pulmonary tissue is stressed.

A clip technique for ligation of the ductus arteriosus in premature infants is presented.