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Introduction: Most traumatic lung injuries are managed non-operatively. There is a paucity of recent data on the outcomes of operatively managed lung injuries. The aim of our study is to determine the survival rates of operatively managed traumatic lung injury patients on a nationwide scale., Methods: We performed a retrospective analysis of the ACS-TQIP 2017-2020. We included all adult trauma patients with lung injuries that underwent operative management. Patients were stratified based on type of surgery into 3 groups (wedge resection, lobectomy, pneumonectomy). The outcome was mortality. Multivariable logistic regression analysis was performed to identify the independent predictors of mortality., Results: We identified a total of 170,377 patients with lung injuries, out of which 2159 (1.3%) patients underwent operative management (Wedge resection [61%], Lobectomy [31%], Pneumonectomy [8%]). Among operatively managed patients, the mean (SD) age was 37 (16) years, and 86% were male. Overall, 65% sustained penetrating injuries, with a median [IQR] ISS of 25 [16 - 33], and median [IQR] lung injury AIS severity of 4 [3 - 4]. About 7% of the patients suffered hilar injuries. The mean (SD) SBP on arrival was 108 (43) and the median [IQR] time to surgery was 177 [52 - 5351] minutes. The median hospital LOS was 10 [1 - 19] days, and overall mortality rate was 30%. On univariate analysis, patients undergoing pneumonectomy had the highest mortality (54%), followed by lobectomy (33%), and wedge resection (25%). On multivariable regression analysis, hilar injuries (aOR 1.9, 95%CI = 1.06 - 2.80, P = 0.029), increasing age (aOR 1.02, 95%CI = 1.01 - 1.03, P = 0.001), concomitant head (aOR 1.34, 95%CI = 1.22 - 1.47, P < 0.001) and abdominal injuries (aOR 1.42, 95%CI = 1.31 - 1.54, P < 0.001) were independent predictors of mortality., Conclusions: Nearly 1 in 3 patients with lung injuries who were managed operatively did not survive their index admission. These findings highlight that operatively managed lung injuries still carry a high risk of mortality and should be reserved for selected patients. The decision for surgery in patients with concomitant head or abdominal injuries must be taken on a case-to-case basis., (Copyright © 2024 Elsevier Inc. All rights reserved.)

We encountered a case in which emergency surgery was performed for a penetrating lung injury complicated by a hemodynamic cerebral infarction. A 45-year-old man sustained a chest injury due to a scattered piece of metal and was admitted to a nearby hospital. He was confirmed to have hemorrhagic shock due to a right hemopneumothorax, and a chest tube was inserted he was transferred to our hospital. Chest radiography and computed tomography (CT) revealed a metal fragment in the right lung and confirmed the diagnosis of a penetrating lung injury due to a foreign body. The patient also presented with total blindness of an unknown etiology. Emergency surgery was performed to treat the injury and remove the foreign body. A large amount of blood and hematoma were removed from the right thoracic cavity, and a metal fragment was found in the lower lobe of the right lung. After removing the foreign body, pulmonary suturing was performed. On the following day, head magnetic resonance imaging revealed multiple cerebral infarctions in the bilateral occipital lobes, left frontal lobe, and left cerebellar hemisphere. However, no vascular occlusion or thrombus was found, and the patient was diagnosed with hemodynamic cerebral infarction due to hemorrhagic shock.

Background: Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure., Case Description: A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery., Conclusions: Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients., (© 2024. The Author(s).)

Introduction: Traumatic pulmonary injuries are common in chest trauma. Persistent air leaks occur in up to 46% of patients depending on injury severity. Prolonged leaks are associated with increased morbidity and cost. Prior work from our first-generation pectin patches successfully sealed pulmonary leaks in a cadaveric swine model. We now test the next-generation pectin patch against wedge resection in the management of air leaks in anesthetized swine., Methods: A continuous air leak of 10% to 20% percent was created to the anterior surface of the lung in intubated and sedated swine. Animals were treated with a two-ply pectin patch or stapled wedge resection (SW). Tidal volumes (TVs) were recorded preinjury and postinjury. Following repair, TVs were recorded, a chest tube was placed, and animals were observed for presence air leak at closure and for an additional 90 minutes while on positive pressure ventilation. Mann-Whitney U test and Fisher's exact test used to compare continuous and categorical data between groups., Results: Thirty-one animals underwent either SW (15) or pectin patch repair (PPR, 16). Baseline characteristics were similar between animals excepting baseline TV (SW, 10.3 mL/kg vs. PPR, 10.9 mL/kg; p = 0.03). There was no difference between groups for severity of injury based on percent of TV loss (SW, 15% vs. PPR, 14%; p = 0.5). There was no difference in TV between groups following repair (SW, 10.2 mL/kg vs. PPR, 10.2 mL/kg; p = 1) or at the end of observation (SW, 9.8 mL/kg vs. PPR, 10.2 mL/kg; p = 0.4). One-chamber intermittent air leaks were observed in three of the PPR animals, versus one in the SW group ( p = 0.6)., Conclusion: Pectin patches effectively sealed the lung following injury and were noninferior when compared with wedge resection for the management of acute traumatic air leaks. Pectin patches may offer a parenchymal sparing option for managing such injuries, although studies evaluating biodurability are needed., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

A 84-year-old man was diagnosed with complete atrioventricular block and underwent pacemaker implantation( PMI). Two days after the PMI, chest X-ray revealed left pneumothorax, and a chest tube was inserted. The pneumothorax did not improve, and computed tomography revealed left lung injury by the right ventricular lead. Surgical procedure through median sternotomy was performed, and the penetrated lead was removed. The injured right ventricle and left lung were repaired. Ten days after the surgical procedure, intravenous implantation of new right ventricular lead was performed. He was discharged 38 days after the surgical procedure.

We report the case of a patient with injuries to multiple organs as a result of attempted suicide with a nail gun. The patient shot 12 nails into his chest, causing damage to multiple organs, including the heart, lungs, and stomach. With timely emergency surgery, we successfully removed all the nails, and the patient was discharged from the hospital two weeks after surgery.

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively. Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management., Competing Interests: Conflict of Interest: The authors declare that they have no conflict of interest., (Copyright © 2021 Colombia Medica.)

Pneumonectomy after traumatic lung injury (TLI) is associated with shock, increased pulmonary vascular resistance, and eventual right ventricular failure. Historically, trauma pneumonectomy (TP) mortality rates ranged between 53 and 100%. It is unclear if contemporary mortality rates have improved. Therefore, we evaluated outcomes associated with TP and limited lung resections (LLR) (i.e., lobectomy and segmentectomy) and aimed to identify predictors of mortality, hypothesizing that TP is associated with greater mortality versus LLR. We queried the Trauma Quality Improvement Program (2010-2016) and performed a multivariable logistic regression to determine the independent predictors of mortality in TLI patients undergoing TP versus LLR. TLI occurred in 287,276 patients. Of these, 889 required lung resection with 758 (85.3%) undergoing LLR and 131 (14.7%) undergoing TP. Patients undergoing TP had a higher median injury severity score (26.0 vs. 24.5, p = 0.03) but no difference in initial median systolic blood pressure (109 vs. 107 mmHg, p = 0.92) compared to LLR. Mortality was significantly higher for TP compared to LLR (64.9% vs 27.2%, p < 0.001). The strongest independent predictor for mortality was undergoing TP versus LLR (OR 4.89, CI 3.18-7.54, p < 0.001). TP continues to be associated with a higher mortality compared to LLR. Furthermore, TP is independently associated with a fivefold increased risk of mortality compared to LLR. Future investigations should focus on identifying parameters or treatment modalities that improve survivability after TP. We recommend that surgeons reserve TP as a last-resort management given the continued high morbidity and mortality associated with this procedure.

The resection of lung parenchyma for thoracic trauma is uncommon. Different surgical procedures with a wide range of complexities have been described depending on the severity of trauma and the presence of associated injuries. The aim of this study was to analyze outcomes of wedge resection, lobectomy, and pneumonectomy. Data for this study were obtained from an eight-year retrospective National Trauma Data Bank study (2007-2015). Adult patients who sustained severe chest trauma (Abbreviated Injury Scale > 3) that required any type of lung resection were included. Propensity score (PS) analysis was adopted. Overall, 3107 patients were included. Wedge resection was performed in 54.3 per cent, lobectomy in 38.2 per cent, and pneumonectomy in 7.5 per cent of patients. Longer in-hospital length of stay ( P = 0.01), ICU length of stay ( P = 0.002), and mechanical ventilation days ( P = 0.038) were found in case of major resections. The overall morbidity and mortality were 32 per cent and 27.5 per cent, respectively. A stepwise increase in mortality occurred when comparing wedge (20.3%), lobectomy (30.8%), and pneumonectomy (63.4%) ( P < 0.001). After PS analysis, lobectomy and pneumonectomy were associated with higher mortality compared with wedge resection (odds ratio [OR] 1.42; 95% confidence interval 1.26-1.71 and OR 4.16; 95% confidence interval 2.84-6.07, respectively). Similarly, after PS analysis, lobectomy and pneumonectomy were associated with higher overall complications compared with wedge resection (OR 1.21 and OR 1.56, respectively). Comparable results were found in the subgroup analysis of patients with isolated lung injury. After PS matching, lobectomy and pneumonectomy were associated with significantly higher morbidity and mortality compared with nonanatomical wedge resection.

Chest trauma, penetrating or blunt is common in this era of motor vehicle accidents, violence and terrorism in South Asia. Islamabad is the capital of Pakistan but there is no dedicated chest surgery unit in any government sector hospitals. Gunshot chest, is therefore managed by general surgery team in our tertiary care setting i.e. Federal Government Polyclinic Hospital and Post Graduate Medical Institute, Islamabad. We report a case of gunshot chest with lung contusion and open pneumothorax with a chest wall defect of 10 x 15 cm. in March 2015, this young man presented in emergency department of Federal Government Polyclinic Hospital (FGPC), Post Graduate Medical Institute (PGMI) Islamabad in shock after self-inflicted point blank suicidal gunshot to his left anterolateral chest. After primary resuscitation, the patient was shifted to OR, and a left anterolateral thoracotomy performed. Lung contusion was repaired and chest drain placed. The challenging task of closing the huge chest wall defect was performed by rotating the left latissimus dorsi muscle flap. The patient was shifted to ICU and remained stable postoperatively.

Objective: To establish the indications for optimal open lung surgery in patients with severe blunt chest injury., Material and Methods: Hematomas, lung wounds and purulent pulmonary complications were studied in four groups of victims. Causes of injuries included road accidents ( n =426), falling and beating ( n =387), catatrauma ( n =217), squeezing the body with a massive weight ( n =46). Majority of victims ( n =731, 67.9%) were transferred to the hospital within 1-5 hours after injury; 345 (32.1%) patients were transferred from other hospitals to treat combined injuries of head, chest, abdomen and complications within 1-49 days after injury., Results: Lung surgery was applied in 48 patients. Typical resections and pneumonectomies made up 77.1%. Indications for surgery included lung wounds complicated by pulmonary hemorrhage grade IIa and severe hemothorax, intrapulmonary hematoma ≥6 cm with high risk of bleeding and suppuration, gangrene, gangrenous and purulent abscesses of aspiration genesis, lung cancer first diagnosed in victims. Postoperative mortality was 14.6%. Twelve victims with unrecognized deep lung wounds and pulmonary root rupture were not operated. Thus, 5.6% of victims with severe blunt chest trauma need for open lung surgery.

It has been previously suggested that lung tissue remains viable without blood supply from the pulmonary artery (PA). However, our experience demonstrates otherwise. We present 2 cases of accidental left lower lobe PA occlusion during upper lobectomy causing ischaemic changes to the remaining lung tissue. Both patients became septic secondary to necrosis of infarcted lung and required completion pneumonectomy. Development of collateral circulation to bypass the occluded PA may occur but is often insufficient to support the affected lung tissue. Unless the patient is medically unfit, resection of the ischaemic lung should be undertaken., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The multiple inert gas elimination technique (MIGET) using gas chromatography (GC) is an established but time-consuming method of determining ventilation/perfusion (VA/Q) distributions. MIGET-when performed using Micropore Membrane Inlet Mass Spectrometry (MMIMS)-has been proven to correlate well with GC-MIGET and reduces analysis time substantially. We aimed at comparing shunt fractions and dead space derived from MMIMS-MIGET with Riley shunt and Bohr dead space, respectively. Thirty anesthetized pigs were randomly assigned to lavage or pulmonary embolism groups. Inert gas infusion (saline mixture of SF6, krypton, desflurane, enflurane, diethyl ether, acetone) was maintained, and after induction of lung damage, blood and breath samples were taken at 15-min intervals over 4 h. The samples were injected into the MMIMS, and resultant retention and excretion data were translated to VA/Q distributions. We compared MMIMS-derived shunt (MM-S) to Riley shunt, and MMIMS-derived dead space (MM-VD) to Bohr dead space in 349 data pairs. MM-S was on average lower than Riley shunt (- 0.05 ± 0.10), with lower and upper limits of agreement of - 0.15 and 0.04, respectively. MM-VD was on average lower than Bohr dead space (- 0.09 ± 0.14), with lower and upper limits of agreement of - 0.24 and 0.05. MM-S and MM-VD correlated and agreed well with Riley shunt and with Bohr dead space. MM-S increased significantly after lung injury only in the lavage group, whereas MM-VD increased significantly in both groups. This is the first work evaluating and demonstrating the feasibility of near real-time VA/Q distribution measurements with the MIGET and the MMIMS methods.

Background: Serious chronic medical conditions occur in childhood cancer survivors. We aimed to investigate incidence of and risk factors for end-organ damage resulting in registration on a waiting list for or receiving a solid organ transplantation and 5-year survival following these procedures., Methods: The Childhood Cancer Survivor Study (CCSS) is a retrospective cohort of individuals who survived at least 5 years after childhood cancer diagnosed at younger than 21 years of age, between Jan 1, 1970, and Dec 31, 1986, at one of 25 institutions in the USA. We linked data from CCSS participants treated in the USA diagnosed between Jan 1, 1970, and Dec 31, 1986 (without solid organ transplantation before cohort entry) to the Organ Procurement and Transplantation Network-a database of all US organ transplants. Eligible participants had been diagnosed with leukaemia, lymphoma, malignant CNS tumours, neuroblastoma, Wilms' tumours, and bone and soft tissue sarcomas. The two primary endpoints for each type of organ transplant were date of first registration of a transplant candidate on the waiting list for an organ and the date of the first transplant received. We also calculated the cumulative incidence of being placed on a waiting list or receiving a solid organ transplantation, hazard ratios (HRs) for identified risk factors, and 5-year survival following transplantation., Findings: Of 13 318 eligible survivors, 100 had 103 solid organ transplantations (50 kidney, 37 heart, nine liver, seven lung) and 67 were registered on a waiting list without receiving a transplant (21 kidney, 25 heart, 15 liver, six lung). At 35 years after cancer diagnosis, the cumulative incidence of transplantation or being on a waiting list was 0·54% (95% CI 0·40-0·67) for kidney transplantation, 0·49% (0·36-0·62) for heart, 0·19% (0·10-0·27) for liver, and 0·10% (0·04-0·16) for lung. Risk factors for kidney transplantation were unilateral nephrectomy (HR 4·2, 95% CI 2·3-7·7), ifosfamide (24·9, 7·4-83·5), total body irradiation (6·9, 2·3-21·1), and mean kidney radiation of greater than 15 Gy (>15-20 Gy, 3·6 [1·5-8·5]; >20 Gy 4·6 [1·1-19·6]); for heart transplantation, anthracycline and mean heart radiation of greater than 20 Gy (dose-dependent, both p<0·0001); for liver transplantation, dactinomycin (3·8, 1·3-11·3) and methotrexate (3·3, 1·0-10·2); for lung transplantation, carmustine (12·3, 3·1-48·9) and mean lung radiation of greater than 10 Gy (15·6, 2·6-92·7). 5-year overall survival after solid organ transplantation was 93·5% (95% CI 81·0-97·9) for kidney transplantation, 80·6% (63·6-90·3) for heart, 27·8% (4·4-59·1) for liver, and 34·3% (4·8-68·6) for lung., Interpretation: Solid organ transplantation is uncommon in ageing childhood cancer survivors. Organ-specific exposures were associated with increased solid organ transplantation incidence. Survival outcomes showed that solid organ transplantation should be considered for 5-year childhood cancer survivors with severe end-organ failure., Funding: US National Institute of Health, American Lebanese Syrian Associated Charities, US Health Resources and Services Administration., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Previous studies suggest that transbronchial lung biopsy using a cryoprobe is superior to transbronchial lung biopsy using forceps for evaluating lung grafts, although the technique can be associated an increase in complications. Because cryoprobe experience is limited, assessment of a greater number of cases is warranted. This prospective study evaluates the diagnostic yield, complications, and risk factors associated with the cryoprobe technique., Methods: From April 2013 to April 2016, 321 consecutive cryoprobe transbronchial biopsies were indicated in single or bilateral lung transplant patients with acute or chronic clinical lung injury or in asymptomatic patients before hospital discharge after lung transplantation., Results: With a mean of 4.32 lung parenchyma specimens per procedure, adequate alveolar lung parenchyma was obtained in 96.6% (84.27 ± 44.14 mm 2 ) of cases. Obtaining at least 4 samples increased the histological diagnostic certainty (P < .001). Moderate to severe bleeding was observed in 7.48% of patients and was significantly more frequent in patients with unilateral transplantation (odds ratio, 0.10; 95% confidence interval, 0.02-0.30; P < .001) and in those with high blood pressure during scanning (odds ratio, 0.31; 95% confidence interval, 0.12-0.86; P = .019). Pneumothorax was observed in 7.7% of the patients, but only 3.7% of these patients required pleural drainage., Conclusions: Obtaining 4 or more cryobiopsy samples is valuable and safe for lung allograft monitoring. Being a recipient of a unilateral lung transplant or having arterial hypertension during bronchoscopy seem to be risk factors associated with increased bleeding., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Penetrating neck and chest trauma is a very common entity in emergency medicine that usually requires surgical treatment. Our case report illustrates the case of a 27-year-old Arabian man with hemopneumothorax associated with pneumomediastinum due to an unusual occupational injury., Case Presentation: A metal sliver, coming from an axe using for wood chopping, penetrated the neck of a 27-year-old Arabian man in the left supraclavicular region mimicking a gun bullet; the entrance hole was at the left pleural dome where the sliver had just penetrated the apex of the lung passing through the upper lobe of his left lung creating an exit wound in the dorsal segment of the same lobe arriving in the posterior thoracic wall. Biportal video-assisted thoracic surgery was performed to remove blood clots and the unusual foreign body.  CONCLUSION: In the literature, there are several case series about this topic, with some of them reporting unusual foreign bodies that lead to penetrating trauma. However, to the best of our knowledge, no cases like the one we have reported are described in the current literature.

Background/aim: Video-assisted thoracic surgery (VATS) for ipsilateral reoperations is challenging because of the potential for pleural adhesions. Insertion of the initial port can lead to lung injury because of the blinded intrathoracic area. We assessed the usefulness of ultrasonography before VATS to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS., Patients and Methods: Thirty-three patients who underwent repeat VATS for ipsilateral pulmonary lesions were included. All patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions using the lung sliding sign., Results: Seven adhesions were found at the VATS ports. Two of these adhesions were not evaluated as pleural adhesions using ultrasonography; however, they were loose. All initial ports were inserted without lung injury. There were no major complications., Conclusion: Preoperative detection of pleural adhesions using ultrasonography can determine the best initial port for secondary ipsilateral VATS., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Rationale: Damage control is a staged surgical approach to manage polytraumatized patients. The damage control approach comprises three steps. First, bleeding is controlled and fractures are stabilized temporarily; second, vital parameters are stabilized and the child is rewarmed in the intensive care unit; and third, the child is reoperated for definitive repair of injuries. We aimed to describe the feasibility of the damage control orthopedic approach in a child., Patient Concerns: An 8-year-old girl fell from the balcony of the 5th floor onto concrete pavement and was admitted to our accident and emergency ward in a stable cardiorespiratory state, but with gross deformity of the lower limbs, left thigh, and forearm., Diagnoses: The child had sustained multiple injuries with severe bilateral lung contusion, pneumothorax, fracture of first rib, liver laceration, stable spine fractures, transforaminal fracture of sacrum, pelvic ring fracture, displaced baso-cervical femoral neck fracture, displaced bilateral multifragmental growth plate fractures of both tibiae, fractures of both fibulae, displaced fracture of left forearm, and displaced supracondylar fracture of the humerus., Intervention: In the initial operation, we performed closed reduction and K-wire fixation of the right tibia, closed reduction and external fixation of the left tibia, open reduction and screw osteosynthesis of the femoral neck fracture, closed reduction and K-wire fixation of the radius, and closed reduction of the supracondylar fracture. Subsequently, we transferred the girl to the pediatric intensive care unit for hemodynamic stabilization, respiratory therapy, rewarming, and treatment of crush syndrome. In a third step, 10 days after the injury, we managed the supracondylar fracture of the humerus by closed reduction and K-wire fixation., Outcomes: Growth arrest of the left distal tibial growth plate and osteonecrosis of the femoral head and neck, slipped capital femoris epiphysis (SCFE), and coxa vara of the right femur led to balanced leg length inequality 2 years after the injury. The lesion of the left sciatic nerve improved over time and the girl walked without walking aids and took part in school sports but avoided jumping exercises., Lessons: We emphasize the importance of damage control principles when managing polytraumatized children.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) plays a crucial role when the lung is extensively damaged and when conventional management has failed. ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. A 26-yearold female experienced polytrauma due to a traffic accident 1 h before arrival. Simple chest radiography and chest computed tomography showed a large right hemopneumothorax with atelectasis of the right lung and severe contusion of the left lung. Heparin-free VV-ECMO was applied peripherally via both femoral veins. Under the ECMO support, right lower lobectomy was successfully performed. Although contraindicated in polytraumatic patients with hemorrhagic shock, surgical repair with the application of ECMO may be feasible if bleeding is well controlled. The patient was discharged without significant complications.

Pleural injury and associated air leaks are a major influence on patient morbidity and healthcare costs after lung surgery. Pectin, a plant-derived heteropolysaccharide, has recently demonstrated potential as an adhesive binding to the glycocalyx of visceral mesothelium. Since bioadhesion is a process likely involving the interpenetration of the pectin-based polymer with the glycocalyx, we predicted that the pectin-based polymer may also be an effective sealant for pleural injury. To explore the potential role of an equal (weight%) mixture of high-methoxyl pectin and carboxymethylcellulose as a pleural sealant, we compared the yield strength of the pectin-based polymer to commonly available surgical products. The pectin-based polymer demonstrated significantly greater adhesion to the lung pleura than the comparison products (p < 0.001). In a 25 g needle-induced lung injury model, pleural injury resulted in an air leak and a loss of airway pressures. After application of the pectin-based polymer, there was a restoration of airway pressure and no measurable air leak. Despite the application of large sheets (50 mm 2 ) of the pectin-based polymer, multifrequency lung impedance studies demonstrated no significant increase in tissue damping (G) or hysteresivity (η)(p > 0.05). In 7-day survival experiments, the application of the pectin-based polymer after pleural injury was associated with no observable toxicity, 100% survival (N = 5), and restored lung function. We conclude that this pectin-based polymer is a strong and nontoxic bioadhesive with the potential for clinical application in the treatment of pleural injuries.

Background: Operative interventions are uncommonly required for penetrating pulmonary injuries. Similarly, because their incidence is low, few series appear sporadically in the literature. Objectives of this study are to identify predictors of outcome for patients requiring emergent thoracotomy for penetrating pulmonary injuries and evaluate the use of tissue sparing versus resective techniques for their management., Study Design: This is a retrospective 169-month study of all patients with penetrating pulmonary injuries requiring thoracotomy. The main outcome measures are: physiologic parameters, AAST-OIS injury grade, surgical procedures and mortality. Statistical analysis includes univariate and stepwise logistic regression., Results: 101 patients required thoracotomy for penetrating pulmonary injuries. Mechanism of injury includes: gunshot wounds (GSW)-73 (72%), stab wounds (SW)-28 (33%). Mean systolic BP 97 ± 47, mean HR 92 ± 47, and mean admission pH 7.22 ± 0.17. Mean RTS 6.25 ± 2.7, mean ISS 36 ± 22. The mean estimated blood loss (EBL) was 5277 ± 4955 mls. Predictors of outcome are: admission pH (p = 0.0014), admission base deficit (p < 0.0001), packed red blood cells (PRBCs) transfused (p = 0.023), whole blood transfused (p < 0.01). A total of 143 procedures were required in 101 patients: tissue sparing 114 (80%) versus resective procedures 29 (20%). Only pneumonectomy (p = 0.024) predicted outcome. Overall survival 64/101-64%. American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) injury grades I-III versus IV-VI predicts survival (p < 0.001). Stepwise logistic regression identified AAST-OIS injury grades IV-VI (p = 0.007; OR 6.38 [95% CI 1.64-24.78]), intraoperative dysrhythmias (p = 0.003; OR 17.38 [95% CI 2.59-116.49]) and associated cardiac injuries (p = 0.02; OR 8.74 [95% CI 1.37-55.79]) as independent predictors of outcome., Conclusions: Predictors of outcome for penetrating pulmonary injuries requiring thoracotomy are identified and must be taken into account in their operative management. Tissue sparing techniques-stapled pulmonary tractotomy is once again validated, and it remains effective as the mainstay for their management; however, only pneumonectomy predicts outcome. AAST-OIS injury grades IV-VI predict outcome with higher injury grades requiring resective procedures.

Background: Traumatic pulmonary pseudocysts (TPP) are rare complications of blunt chest trauma. The aim of this study is to increase the understanding of this rare entity with imaging and clinical parameters for preventing complications and determining the correct treatment approach by observing 15 cases., Methods: We retrospectively reviewed the medical data and thoracic computed tomography scans of 185 patients who underwent examinations in our department after chest trauma between July 2014 and December 2015., Results: Fifteen patients had TPPs, and their clinical features and imaging findings were evaluated. Their average age was 26.33 (range, 1-89) years. The cause of TPP was traffic accident in 13 patients and falling from a height in two. Tube thoracostomy was required in five patients. None of the patients required thoracotomy, and 66% of them recovered without any complications. Five patients died because of serious concomitant injuries., Conclusion: Sudden shearing force across the pulmonary parenchyma results in an area of pulmonary contusion and airtransfer from the airway to the contused area, which in turn leads to pneumatocele formation. Conservative treatment is recommended for these patients, but complications can occur because of cyst rupture. Patients should be closely monitored and be made aware of the risk of life-threatening complications.

Background: Ex vivo lung perfusion (EVLP) provides opportunities to treat injured donor lungs before transplantation. We investigated whether lung lavage, to eliminate inflammatory inhibitory components, followed by exogenous surfactant replacement, could aid lung recovery and improve post-transplant lung function after gastric aspiration injury., Methods: Gastric acid aspiration was induced in donor pigs, which were ventilated for 6 hours to develop lung injury. After retrieval and 10 hours of cold preservation, EVLP was performed for 6 hours. The lungs were randomly divided into 4 groups (n = 5, each): (1) no treatment (control), (2) lung lavage, (3) surfactant administration, and (4) lung lavage, followed by surfactant administration. After another 2-hour period of cold preservation, the left lung was transplanted and reperfused for 4 hours., Results: Physiologic lung function significantly improved after surfactant administration during EVLP. The EVLP perfusate from the lavage + surfactant group showed significantly lower levels of interleukin (IL)-1β, IL-6, IL-8, and secretory phospholipase A 2 . Total phosphatidylcholine was increased, and minimum surface tension was recovered to normal levels (≤5 mN/m) in the bronchioalveolar fluid after surfactant administration. Lysophosphatidylcholine in bronchioalveolar fluid was significantly lower in the lavage + surfactant group than in the surfactant group. Post-transplant lung function was significantly better in the lavage + surfactant group compared with all other groups., Conclusions: Lung lavage, followed by surfactant replacement during EVLP, reduced inflammatory mediators and prevented hydrolysis of phosphatidylcholine, which contributed to the superior post-transplant function in donor lungs with aspiration injury., (Copyright © 2017 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Pulmonary toxicity is a devastating complication of bleomycin chemotherapy. This insult is likely exacerbated by the free radical injury induced by high inspired oxygen content, which is required to support these patients. Traditional treatment consists of high-dose corticosteroids. We report the case of a 45-year-old man who developed bleomycin pulmonary toxicity, which failed to respond to treatment with high-dose corticosteroids. We used protective mechanical ventilatory settings while supported on veno-venous extracorporeal membrane oxygenation using a bicaval dual-lumen, single cannula system to allow for lung recovery. This case demonstrates the feasibility of using veno-venous extracorporeal membrane oxygenation to treat bleomycin pulmonary toxicity in a patient who has failed traditional therapy.

Pulmonary contusion is a common finding after blunt chest trauma. It occurs in 23-35% of all cases. Alveolar capillaries are injured due to the trauma, which results in accumulation of blood and other fluids within lung tissue. The fluids interfere with gas exchange, leading to hypoxemia. The consequences of pulmonary contusion include ventilation/perfusion mismatching, increased AV shunts and loss of compliance of lung parenchyma. These physiological consequences are manifested within hours from injury and usually resolve in 7 days. Computed tomography (CT) is a sensitive and main diagnostic tool. Clinical symptoms include hypoxemia and hypercapnia, manifested predominantly during 72 hours from injury. Patients are treated primarily conservatively; surgery may be needed due to haemothorax associated with lung contusion or progression of AV shunts due to localized pulmonary contusion.Key words: pulmonary contusion blunt chest trauma computed tomography.

Purpose: The choice of surgical repair or conservative treatment for iatrogenic tracheobronchial rupture (ITBR) remains controversial. However, thoracic surgeons consider that surgical repair is an important treatment modality. The purpose of this study was to evaluate the clinical results from the perspective of the surgery-preferred group., Methods: We treated 11 patients (8 women and 3 men; age: 52.6 ± 22.9 years) with ITBR from January 2011 to January 2016. A posterolateral thoracotomy or a trans-tracheal approach was performed according to the mechanism of injury., Results: Nine patients underwent surgery, and all patients received primary repair. Five patients received a right posterolateral thoracotomy, whereas one patient received a left posterolateral thoracotomy. No mortality or morbidity related to the surgery was observed. The mechanical ventilation time was 65.9 ± 99.2 hours. The intensive care unit duration was 19.7 ± 33.3 days. Two patients received conservative treatment, and all patients died of another disease that was not related to the conservative treatment., Conclusion: Our mortality or morbidity due to surgery was not higher than world literature results of conservative treatment. We thought surgery is the primary treatment choice for ITBR in the absence of a good indication for conservative treatment.

A 62-year-old man got drunk and dived into the windowpane. He received lacerations on his face and incised wound at his right chest, and was carried to our hospital. Computed tomography showed a glass splinter, about 14 cm of length, in the chest cavity. The patient underwent an emergency thoracotomy and it was found that the glass splinter penetrated through the upper lobe to the hilum. After removing the glass, simple closure by suturing the entrance and exit of the upper lobe was performed. The post operational course was uneventful. Selected patients can be rescued by simple pneumonorrhaphy without resection of lung.

Background: We report the case of a 72-year-old female complaining of hemoptysis due to a thoracic-abdominal knitting needle inserted 33 years ago for self-induced abortion., Case Presentation: The PA/LL chest x-ray showed a metallic foreign body on thorax extending into the abdomen. An CT examination confirmed the transdiaphragmatic knitting needle extending from liver into right upper lobe., Conclusions: Surgical removal of the foreign body and wedge resection were performed with good follow-up results.

Intrapulmonary aberrant needles are rarely encountered in clinical practice. A 82-year-old woman, though she was asymptomatic, was referred to our department due to an abnormal shadow on a chest X-ray. Chest X-ray and chest computed tomography showed a foreign body suspected to be a sewing needle in the left upper lobe. The needle was successfully removed by video-assisted thoracoscopic surgery.

Complications caused by a scapular body fracture are rare, and usually occur due to concomitant injuries or nonunion. Intrathoracic displacement of a fractured scapula has only been described in two reports involving adolescents. In this report, we describe a 6-year-old boy with a parenchymal lung injury caused by a greenstick fracture fragment of the scapular body after being struck by a dump truck. Three-dimensional CT (3D CT) scan showed an incomplete fractured fragment impaling the left lung parenchyma resulting in pneumothorax, parenchymal contusion, and pneumatocele in the left upper lobe. The patient underwent emergency open reduction of the scapular fracture and chest tube insertion. A rare subtype of scapular fracture with resultant fragment rotation and intrathoracic penetration can injure the lung parenchyma. To the best of our knowledge, lung injury caused by incomplete fracture of the scapula in patients younger than 10 years has not been reported previously.

We present a rare case of intercostal lung herniation due to blunt trauma. A 40-year-old man was admitted to our hospital with lung herniation due to falling off a donkey. Computed tomography demonstrated a fracture of the 8th left rib, a comminuted fracture of the 9th rib, and lung herniation into the 8th intercostal space. The herniation was repaired using a titanium prosthetic rib, a rib plate, and Prolene mesh via a thoracotomy., (© The Author(s) 2015.)

Severely shocked patients with thoracic injury often require emergency thoracotomy before a definite diagnosis can be made. A method of management of pulmonary injury is described by performing exploratory resuscitative anterolateral thoracotomy which can be extended across the sternum to the opposite side, if necessary. Control of haemorrhage from the lung is achieved by mass clamping of the hilum and waiting for further resuscitation. After adequate resuscitation, specific management of the lung injury is performed as indicated. This approach was used in 26 cases of life-threatening pulmonary injury. Exposure of the injured lung was good in all cases. Pneumonography was performed in 8, segmental resection in 8 and pneumonectomy in 5 cases. Surgery and resuscitation were abandoned in 5 unsalvageable cases. Eleven patients (42%) survived. All general and trauma surgeons should be able to perform emergency thoracotomy for trauma. The method described here is simple, needs no special equipment and is suitable for most instances.

Traumatic pulmonary pseudocyst is uncommon and usually regresses spontaneously with conservative treatment. In rare cases, surgical intervention may be necessary. A pseudocyst may be treated surgically to prevent potential complications if the patient undergoes a thoracotomy for another reason. We present a patient with hemopneumothorax and traumatic pulmonary pseudocyst after a motor vehicle accident, who was operated on electively due to massive air leak., (© The Author(s) 2015.)