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Study Objective: To determine the incidence of chronic postsurgical pain (CPSP) in women after open thoracotomy. Secondary objectives were to compare relevant patient and procedural variables between women and men., Design: Observational cohort study., Setting: Ten university-affiliated hospitals., Subjects: Ninety-six women and 137 men., Interventions: Scheduled open thoracotomy., Measurements: Pain histories, psychological measures, and perceived health status and catastrophizing scores were obtained. The diagnosis of chronic postsurgical pain was by physical examination at 4 months. Standard preoperative, intraoperative, and postoperative data were also recorded., Main Results: The chronic postsurgical pain incidence was significantly higher in women (53.1%) than in men (38.0%) (p = 0.023). At baseline, women had significantly worse scores on psychological measures (perception of mental state [p = 0.01], depression [p = 0.006], and catastrophizing [p < 0.001]). Women also reported more preoperative pain in the operative area (p = 0.011) and other areas (p = 0.030)., Conclusion: These findings show that the incidence of physician-diagnosed chronic postsurgical pain is higher in women than in men after surgeries involving thoracotomy. Sex and gender should be included in future clinical research on pain in surgical settings., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships, which may be considered as potential competing interests: A.M.P. reports financial support, administrative support, statistical analysis, and writing assistance were provided by Carlos III Institute of Health. A.M.P. reports a relationship with Carlos III Institute of Health that includes funding grants. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The association between cerebral desaturation and postoperative delirium in thoracotomy with one-lung ventilation (OLV) has not been specifically studied., Methods: A prospective observational study performed in thoracic surgical patients. Cerebral tissue oxygen saturation (Scto2) was monitored on the left and right foreheads using a near-infrared spectroscopy oximeter. Baseline Scto2 was measured with patients awake and breathing room air. The minimum Scto2 was the lowest measurement at any time during surgery. Cerebral desaturation and hypersaturation were an episode of Scto2 below and above a given threshold for ≥15 seconds during surgery, respectively. The thresholds based on relative changes by referring to the baseline measurement were <80%, <85%, <90%, <95%, and <100% baseline for desaturation and >105%, >110%, >115%, and >120% baseline for hypersaturation. The thresholds based on absolute values were <50%, <55%, <60%, <65%, and <70% for desaturation and >75%, >80%, >85%, and >90% for hypersaturation. The given area under the threshold (AUT)/area above the threshold (AAT) was analyzed. Delirium was assessed until postoperative day 5. The primary analysis was the association between the minimum Scto2 and delirium using multivariable logistic regression controlled for confounders (age, OLV time, use of midazolam, occurrence of hypotension, and severity of pain). The secondary analysis was the association between cerebral desaturation/hypersaturation and delirium, and between the AUT/AAT and delirium using multivariable logistic regression controlled for the same confounders. Multiple testing was corrected using the Holm-Bonferroni method. We additionally monitored somatic tissue oxygen saturation on the forearm and upper thigh., Results: Delirium occurred in 35 (20%) of 175 patients (65 ± 6 years old). The minimum left or right Scto2 was not associated with delirium. Cerebral desaturation defined by <90% baseline for left Scto2 (odds ratio [OR], 5.82; 95% confidence interval [CI], 2.12-19.2; corrected P =.008) and <85% baseline for right Scto2 (OR, 4.27; 95% CI, 1.77-11.0; corrected P =.01) was associated with an increased risk of delirium. Cerebral desaturation defined by other thresholds, cerebral hypersaturation, the AUT/AAT, and somatic desaturation and hypersaturation were all not associated with delirium., Conclusions: Cerebral desaturation defined by <90% baseline for left Scto2 and <85% baseline for right Scto2, but not the minimum Scto2, may be associated with an increased risk of postthoracotomy delirium. The validity of these thresholds needs to be tested by randomized controlled trials., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Objectives: To compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair., Methods: We included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: 'Recovery Time', 'Postoperative Pain' (at day 2 and 1, 3, 6 and 12 weeks) and 'Treatment Satisfaction'. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores., Results: The response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8-62.1) vs MI 61.7 (43.1-73.9), P = 0.03] and Pain [ST 65.7 (40.1-83.1) vs MI 79.1 (65.5-89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5-100) vs MI 100 (95.0-100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7-18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7-14.5, P = 0.03) was MI surgery., Conclusions: MI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Intercostal nerve blocks with liposomal bupivacaine are commonly used for thoracic surgery pain management. However, dose scheduling is difficult because the pharmacokinetics of a single-dose intercostal injection of liposomal bupivacaine has never been investigated. The primary aim of this study was to assess the median time to peak plasma concentration (Tmax) following a surgeon-administered, single-dose infiltration of 266 mg of liposomal bupivacaine as a posterior multilevel intercostal nerve block in patients undergoing posterolateral thoracotomy., Methods: We chose a sample size of 15 adults for this prospective observational study. Intercostal injection of liposomal bupivacaine was considered time 0. Serum samples were taken at the following times: 5, 15, and 30 minutes, and 1, 2, 4, 8, 12, 24, 48, 72, and 96 hours. The presence of sensory blockade, rescue pain medication, and pain level were recorded after the patient was able to answer questions., Results: Forty patients were screened, and 15 patients were enrolled in the study. Median (interquartile range [IQR]) Tmax was 24 (12) hours (confidence interval [CI], 19.5-28.5 hours) with a range of 15 minutes to 48 hours. The median (IQR) peak plasma concentration (Cmax) was 0.6 (0.3) μg/mL (CI, 00.45-0.74 μg/mL) in a range of 0.3-1.2. The serum bupivacaine concentration was undetectable (<0.2 μg/mL) at 96 hours in all patients. There was significant variability in reported pain scores and rescue opioid medication across the 15 patients. More than 50% of patients had return of normal chest wall sensation at 48 hours. All patients had resolution of nerve blockade at 96 hours. No patients developed local anesthetic toxicity., Conclusions: This study of the pharmacokinetics of liposomal bupivacaine following multilevel intercostal nerve blockade demonstrates significant variability and delay in systemic absorption of the drug. Peak serum concentration occurred at 48 hours or sooner in all patients. The serum bupivacaine concentration always remained well below the described toxicity threshold (2 μg/mL) during the 96-hour study period.

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as "historical" (1973-1975 and 1988-1990) and "modern" (2005-2007 and 2015-2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.

Objective: To evaluate the safety and reproducibility of modified right vertical infra axillary thoracotomy (RVIAT) for repair of sinus venosus defects with right-sided partial anomalous pulmonary venous connection (PAPVC) in children., Methods: Between March 2017 and February 2018, we performed intracardiac repair for sinus venosus defects with right-sided PAPVC in 14 children through modified RVIAT. Median age and weight were 9.5 years and 21 kg, respectively. We modified RVIAT by avoiding central venous cannulation and used total peripheral venous cannulation (right internal jugular vein and right femoral vein). In all children double-patch technique was followed, using untreated autologous pericardium., Results: Intracardiac repair was safely performed in all children. There was no conversion to another approach and there were no complications related to peripheral venous cannulation. All children were in sinus rhythm with no residual defects, with non-obstructive pulmonary venous drainage at the time of discharge and during subsequent follow-ups., Conclusions: Modified RVIAT can be safely performed for repair of sinus venosus defects with right-sided PAPVC, without compromising on the quality of repair. With this modification not only the intracardiac repair was easier, also it provided more working space with minimal rib spreading.

Between 2000 and 2008, the mitral valve (MV) repair rate in patients with severe mitral regurgitation at our low-volume Veterans Affairs hospital was 21%. After instituting a multidisciplinary valve team in 2009, we determined whether this rate increased and characterized the outcomes of patients with degenerative disease. We retrospectively reviewed data from 103 MV operations performed at our hospital between 1/2009 and 8/2016. MV pathology was categorized as degenerative, rheumatic, endocarditis, ischemic, hypertrophic cardiomyopathy, or failed prior MV repair. The surgical techniques used for MV repair were reviewed. For the patients with degenerative disease who underwent MV repair, we assessed leaflet involvement and postoperative valve function. For the full cohort, the MV repair rate was 67% and the 30-day mortality rate was 0.97%. Of the 74 patients with degenerative disease, 64 (86.5%) underwent MV repair (none required reoperation). For these patients, the MV repair rate was significantly higher when the surgical approach was sternotomy rather than minimally invasive right minithoracotomy (92.5% vs 71.4%, P = 0.03). After MV repair, 95.3% of the degenerative disease patients had mild or less mitral regurgitation; median echocardiography follow-up time was 555 days. Anatomic features associated with a reduced MV repair rate in patients with degenerative disease were dystrophic leaflet calcification and severe mitral annular calcification. In an institution with a low volume of MV operations, preoperative surgical planning with a multidisciplinary valve team was associated with improved MV repair rates and excellent repair quality in patients with degenerative valve disease., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Surgical data from the National Lung Screening Trial (NLST) has yet to be closely examined. We sought to analyze surgical procedures and complications from the NLST to determine their relevance to modern surgical practice., Methods: The NLST database was queried for patients who underwent surgical resection for confirmed lung cancer, specifically evaluating postoperative complications. Numerical variables were compared using the Mann-Whitney U test. Categorical variables were compared using the χ 2 test. Logistic regression uni- and multivariable analysis of independent risk factors of postoperative complications was performed., Results: At operation, 80% of patients (n = 821) had lobectomy, 4.1% (n = 42) had pneumonectomy, and 16.1% (n = 166) had sublobar resection, among whom 69% (n = 114) had wedge resection. Only 29.6% (n = 305) of the cohort had a thoracoscopic resection. Although the overall rate of surgical patients with any complication was 31% (n = 318), only 15.5% of patients (n = 160) had major complications, most commonly prolonged air leaks (n = 67, 6.5%). Respiratory failure (n = 28, 2.7%), prolonged ventilation (n = 9, 0.9%), myocardial infarction or cardiac arrest (n = 7, 0.7%), and stroke (n = 2, 0.2%) were rare events. Overall 30-day mortality in patients undergoing resection was 1.7% (n = 18). On multivariable analysis, greater smoking pack history (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.001-1.01) and pulmonary comorbidities (OR, 1.34; 95% CI, 0.98-1.82) were significant or approached significance for an association with complications/death, whereas sublobar resection (OR, 0.59; 95% CI, 0.38-0.94) and video-assisted thoracoscopic surgery approach (OR, 0.76; 95% CI, 0.56-1.04) were significant or approached significance for an association with decreased rates of complications/death., Conclusions: Operative mortality and postoperative morbidity were very low in patients undergoing resection for screen-detected lung cancer. Increased use of sublobar resection and minimally invasive surgical approaches may be associated with fewer complications., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Therapeutic ultrasound (TU) alleviates nerve injury-associated pain, while the molecular mechanisms are less clear. This is an investigator-initiated experimental study to evaluate the mechanisms and effects of ultrasound on prolonged post-thoracotomy pain in a rodent model., Methods: The rats were randomly separated into four groups (n=8 per group): sham-operation (sham; group 1), thoracotomy and rib retraction (TRR; group 2), and TRR procedure followed by TU (TRR+TU-3; group 3) or TU with the ultrasound power turned off (TRR+TU-0; group 4). TU was delivered daily, beginning on postoperative day 11 (POD 11) for the next 2 weeks. Mechanical sensitivity, subcutaneous tissue temperature, and spinal substance P and interleukin-1 beta (IL-1β) were evaluated on PODs 11 and 23., Results: Group 3, which received ultrasound treatment (3 MHz; 1.0 W/cm 2 ) for 5 min each day, demonstrated higher mechanical withdrawal thresholds when compared with the group without ultrasound intervention (group 2) or sham ultrasound (group 4). Ultrasound treatment also inhibited the upregulation of spinal substance P and IL-1β measured from spinal cord dorsal horns extract and increased subcutaneous temperature., Conclusions: The results of this study suggest an increase in mechanical withdrawal thresholds and subcutaneous temperature, as well as a downregulation of spinal substance P and IL-1β, in the group which received ultrasound treatment. The regulation of spinal substance P and IL-1β may mediate potential effects of this non-invasive treatment., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient-prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy., Methods: Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed., Results: Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m 2 . All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%., Conclusions: Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.

Objectives: To investigate the relationships between secondhand smoke (SHS) exposure and oxygenation during one-lung ventilation (OLV) in lobectomy surgery and between SHS exposure and postoperative analgesic consumption., Design: Prospective study., Setting: University, Faculty of Medicine, operating room., Participants: Sixty adult patients with American Society of Anesthesiologists score II to III, aged 18 to 65 years, with a body mass index (BMI) <35 kg/m 2 scheduled for lobectomy surgery by open thoracotomy., Interventions: Patients were divided into 2 groups: the SHS group (n = 30) (urine cotinine level ≥6.0 ng/mL) and the NS (nonsmoker) group (n = 30) (urine cotinine level <6.0 ng/mL and no smoking history). SHS exposure was defined according to a previously published algorithm., Measurements and Main Results: Noninvasive blood pressure, electrocardiography, capnography, and peripheral oxygen saturation were monitored, and intra- and postoperative arterial oxygen tension (PaO 2 ), arterial carbon dioxide tension (PaCO 2 ), and intraoperative peak airway pressure were compared between the 2 groups. Postoperative analgesic consumption was calculated. No significant differences in demographics or preoperative data were noted between the 2 groups. PaO 2 values 10 minutes after OLV onset and 10 minutes after the end of OLV were increased significantly in the NS group compared with those in the SHS group (p < 0.05). PaO 2 values after 10 minutes of OLV in the NS and SHS groups were 285.5 ± 90 mmHg and 186.7 ± 66 mmHg, respectively. PaO 2 values after OLV termination in the NS and SHS groups were 365.8 ± 58 mmHg and 283.6 ± 64 mmHg (p < 0.05), respectively. PaCO 2 values 10 minutes after OLV onset, 10 minutes after the end of OLV, at the end of surgery, and upon arrival in the intermediate care unit were significantly different between the 2 groups (p < 0.05)., Conclusion: The present study demonstrated that during OLV, patients exposed to SHS exhibited significantly lower arterial oxygen pressure compared with nonsmokers. Arterial carbon dioxide values were increased significantly in SHS-exposed patients. Morphine consumption for postoperative analgesia also was increased in patients exposed to SHS compared with that in nonsmokers., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open thoracotomy. We have reviewed our data to observe if the surgical management of these lesions has evolved over the last years., Methods: We retrospectively reviewed the records of the patients who were operated for an ILS either by posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016., Results: Eighteen patients were operated for a SIL during this period. Prior to 2011, all resections were performed by thoracotomy (n=6) and after 2011 the surgical approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS were more frequently encountered on the left side (n=12, 66.6 %) than on the right one (n=6, 33.3 %) and exclusively in the lower lobes. All patients of the PLT group underwent a lobectomy. In the TS group, 5 patients underwent a sublobar resection (2 segmentectomiesS 9+10 , 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45 %) had complications versus one patient (14 %) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group., Conclusions: These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, thoracoscopically., (Copyright © 2018 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Background: The analgesic effects of dexamethasone have been reported previously, and the present study determined the effects of preoperative dexamethasone on postoperative pain in patients who received thoracotomy., Methods: Forty patients participated in this randomized, double-blind study. All patients received either dexamethasone via a 0.1 mg/kg intravenous bolus before anesthetic induction or an equal volume of saline. Postoperative analgesia was provided to both groups via epidural patient-controlled analgesia (PCA), which consisted of 250 μg of sufentanil in 250 mL of ropivacaine (0.18%) for 72 h. The primary outcome was the cumulative consumption of epidural PCA at postoperative 24 and 72 h. The secondary outcomes were the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay., Results: No significant differences was observed in the consumption of epidural PCA between the control and dexamethasone infusion groups at 24 h (63.6 [55.9-72.7] vs. 68.5 [60.2-89.0] ml, P = 0.281) and 72 h (199.4 [172.4-225.1] vs. 194.7 [169.1-252.2] ml, P = 0.890). Moreover, there was no significant difference in the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay., Conclusion: A single intravenous administration of dexamethasone during the preoperative period does not reduce opioid consumption and post-thoracotomy pain., Trial Registration: The study was registered at http://cris.nih.go.kr ( KCT0000359 ) and was conducted from December 2011 to October 2012.

Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.

Background Pediatric chest injuries were infrequent in our practice, but the outbreak of the Syrian crisis resulted in an increase in number and a change in the pattern of thoracic trauma incidents. We compared our experience of pediatric chest injuries before and during the crisis. Methods We reviewed the records of 256 children aged 12.8 ± 5 years who were admitted to our hospital with the diagnosis of chest trauma over a 12-year period. Collected data included mechanism of injury, associated injuries, method of management, length of hospital stay, complications, and mortality. Results The incidence of pediatric chest injuries increased significantly following the outbreak of the crisis, and penetrating injuries prevailed, mainly due to shrapnel, bullets, and stab wounds. Forty percent of patients with blunt injuries and 20% of those with penetrating injuries were managed conservatively, whereas urgent thoracotomies were indicated in 10%, mostly in patients with penetrating injuries. Associated injuries were more frequent in patients with blunt injuries and resulted in a longer hospital stay and an increased mortality rate. The overall mortality rate was 7.8% and it was higher in children younger than 7 years of age and in patients who had been subjected to blunt injuries. Conclusions There has been a recent substantial upsurge in the incidence of pediatric thoracic trauma, with a predominance of penetrating injuries. Most patients could be managed nonoperatively, but a small subset required an open thoracotomy. The presence of associated injuries constitutes the main determinant of prognosis in this group of patients.

Objectives: To determine the incidence of ipsilateral shoulder pain (ISP) with the therapeutic use of parecoxib compared with a placebo after thoracotomy., Design: A prospective, randomized, double-blind, placebo-controlled trial., Setting: A tertiary-care university hospital., Participants: Adult patients undergoing an elective thoracotomy between June 2011 and February 2015., Interventions: Patients were allocated randomly into the parecoxib group (n = 80) and the control group (n = 80). In the parecoxib group, 40 mg of parecoxib was diluted into 2 mL and given intravenously 30 minutes before surgery and then every 12 hours postoperatively for 48 hours. In the control group, 2 mL of normal saline was given to the patients at the same intervals., Measurements and Main Results: A numerical rating scale was used to assess the intensity of ISP at 2, 6, 12, 24, 48, 72, and 96 hours after surgery. Intravenous morphine (0.05 mg/kg) was used as the rescue medication for ISP during the 96-hour period. Baseline characteristics of patients in both groups were comparable. Patients in the parecoxib group had a significantly lower incidence of ISP, both overall (42.5% v 62.0%, p = 0.014) and of moderate-to-severe ISP when compared with the control group (26.2% v 49.4%, p = 0.003). Parecoxib reduced the risk of ISP by a statistically significant 32% (risk ratio, 0.68; 95% confidence interval, 0.50-0.93, p = 0.016). There were no significant differences in the occurrence of adverse effects between the groups., Conclusions: Intravenous parecoxib significantly can reduce the incidence and severity of ISP after thoracotomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the efficacy of ultrasound-guided interscalene nerve block using an ultralow volume of local anesthetic (5 mL of ropivacaine, 0.75%) for the management of post-thoracotomy shoulder girdle pain., Design: Open-cohort, prospective, single-center study., Setting: University hospital., Interventions: Patients with post-thoracotomy shoulder girdle pain (visual analog scale [VAS] ≥5) received an ultrasound-guided interscalene nerve block., Measurements and Main Results: Thirty minutes after block implementation, the VAS was used to quantify pain across the shoulder girdle. The index (I) was calculated to indicate improvement of pain as follows: [Formula: see text] Nerve bocks resulting in I ≥75% were considered excellent. Total tramadol consumption 36 hours after nerve blocks, patients' satisfaction, and complications related to the procedure also were assessed. Patients were segregated in the following 2 groups: group A, which comprised patients with pain in the shoulder area (glenohumeral and acromioclavicular joints) (n = 30), and group B, which comprised patients with pain in the scapula (n = 17). I was significantly greater in group A (88.3% ± 14%) than in group B (43.2% ± 22%). In groups A and B, 90% and 11% of patients, respectively, demonstrated excellent pain control. Total tramadol consumption in group A, 25 (0-100) mg, was significantly less that of group B, 250 (150-500) mg. Patients' satisfaction also was significantly higher in group A compared with group B. No complications were recorded., Conclusions: Ultrasound-guided interscalene nerve block can substantially alleviate post-thoracotomy pain in the shoulder but not in the scapular area., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Here, we report concomitant resection of the left atrial appendage through the transverse sinus during minimally invasive aortic valve replacement via right anterolateral thoracotomy. The left atrial appendage was exposed by raising the collapsed ascending aorta and was safely resected using a surgical stapling device. This procedure is a feasible option in elderly patients, for whom a percutaneous procedure would be inappropriate, and could be useful for preventing thromboembolic and hemorrhagic complications.

Objective: The aim of this study was to reveal the mechanism of improved arterial oxygenation by measuring the changes in oxygenation before and after initiation of left heart bypass (LHB) during one-lung ventilation (OLV) for thoracic aortic surgery., Design: Prospective, observational study., Setting: Single-institution, private hospital., Participants: The study comprised 50 patients who underwent aortic surgery via a left thoracotomy approach with LHB circulatory support., Interventions: Patients were ventilated using pure oxygen during OLV, and the ventilator setting was left unchanged during the measurement period., Measurements and Main Results: The measurement of partial pressure of arterial oxygen (PaO 2 ) was made at the following 4 time points: 2 minutes after heparin infusion (point 1 [P1]), 2 minutes after inflow cannula insertion through the left pulmonary vein (P2), immediately before LHB initiation (P3), and 10 minutes after LHB initiation (P4). The mean±standard deviation (mmHg) of PaO 2 measurements at the P1, P2, P3, and P4 time points were 244±121, 250±123, 419±122, and 430±109, respectively, with significant increases between P1 and P3, P1 and P4, P2 and P3, and P2 and P4 (p<0.0001, respectively). No significant increase in PaO 2 was seen between P1 and P2 or between P3 and P4., Conclusions: The improved arterial oxygenation during OLV in patients who underwent thoracic aortic surgery using LHB can be attributed to the insertion of an inflow cannula via the left pulmonary vein into the left atrium before LHB., (Copyright © 2017 Elsevier Inc. All rights reserved.)

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement, our technique should offer easier access and better results than other currently available implantation methods., (© The Author 2016. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Management of patients with primary spontaneous pneumothorax is controversial. We sought to review our experience in the treatment of primary spontaneous pneumothorax (PSP) by comparing outcomes from video-assisted thoracoscopic surgery (VATS) with thoracotomy., A retrospective review of electronic and paper medical charts identified 104 consecutive operations performed at University of Kentucky Chandler Medical Center for spontaneous pneumothorax management between the dates of January 2000 and January 2013. Follow-up phone calls were made to ensure absence of re-ocurrences outside of our hospital system., Eighty-eight patients (85%) underwent VATS repair with unilateral and contralateral recurrence rates of 7% and 11% respectively. Mean operative time was 97 minutes; mean postoperative hospital stay was 6 days. Mechanical pleurodesis/pleurectomy was performed in 94% of cases. Comparatively 16 patients (16%) underwent thoracotomy repair with unilateral and contralateral recurrence rates of 0.00% and 6% respectively. Mean operative time for the thoracotomy group was 188 minutes; mean postoperative hospital stay was 5 days. Mechanical pleurodesis was performed 12 times (75%)., In our study, the VATS group had a significant reduction in operating room time (P = .001), a non-significant increase in unilateral recurrence (p = .587), and no reduction in postoperative length of stay. Contralateral recurrence rate did not vary between groups.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement our technique should offer easier access and better results than other currently available implantation methods., (© The Author 2016. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: The purpose of this study was to examine trends in the treatment of patients with infectious parapneumonic effusions in U.S. children's hospitals over the past decade., Methods: The PHIS database was queried for patients younger than 18years old with pneumonia and pleural effusion in three yearlong periods over the past decade. Variables included age, gender, payer, race/ethnicity, hospital region, hospital type, markers of illness severity, and treatment group (antibiotics alone, chest tube thoracostomy±thrombolytics, video-assisted thoracoscopy (VATS), or thoracotomy)., Results: 5569 patients were included in the final analysis. The proportion of patients treated with antibiotics alone increased from 62% to 74% from 2004 to 2014 (p<0.001). Among patients requiring pleural space drainage, the frequency of VATS peaked in 2009 (50.8%), dropping to 36.4% in 2014 (p<0.001), while tube thoracostomy, usually with fibrinolytics, rose from 39.0% in 2009 to 53.2% in 2014 (p<0.001)., Conclusion: In a select cohort of free-standing, tertiary care U.S. children's hospitals, antibiotic administration alone remains the most common treatment approach to infectious parapneumonic effusions. VATS treatment for those patients requiring pleural space drainage is being gradually supplanted by thoracostomy tube placement with instillation of fibrinolytics., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The present study was performed to evaluate the effect of postoperative administration of pregabalin in patients who reported moderate-to-severe pain after epidural analgesia following thoracotomy., Design: An open-label, randomized, controlled, parallel-group study., Setting: A single center in Japan., Participants: Consecutive patients (aged≥20 years) who reported moderate-to-severe pain after effectual 2-day epidural analgesia post-thoracotomy for lung cancer from February 2012 to March 2013., Interventions: Patients were assigned to 2 groups: control (control treatment: acetaminophen, 400 mg, and codeine phosphate powder, 20 mg) or pregabalin (pregabalin, 75 mg, plus control treatment). The 12-week study period included 2-week study treatment and 10-week follow-up., Measurements and Main Results: For efficacy, the primary endpoint was the visual analog scale (VAS) scores for pain at rest and with coughing at week 2, and secondary endpoints were the VAS scores for pain and the neuropathic pain questionnaire at week 12. Fifty patients were randomized (25 per group). At week 2, the VAS scores for pain at rest (mean [SD]) were 29.5 (21.9) in the control group and 16.3 (15) in the pregabalin group (p = 0.02); for pain with coughing, the scores were 45.2 (20.9) and 28.8 (25.9), respectively (p = 0.02). VAS scores improved more in the pregabalin group than in the control group over the 12 weeks. Patients free from possible neuropathic pain were 48% of the control group and 88% of the pregabalin group, respectively (p = 0.001)., Conclusions: Postoperative administration of pregabalin effectively reduced post-thoracotomy pain., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Chronic postsurgical pain (CPSP) may affect up to 70% of patients after surgery. Glial and immune mediators have been implicated in the pathogenesis of chronic postsurgical pain. Our objective was to study cerebrospinal fluid (CSF) and serum concentrations of IL-1β, IL-6, IL-8, IL-10, IFNγ and TNFα over a 72-hour period in patients undergoing a thoracotomy and oesophagectomy. Despite adequate pain control, thoracotomy was still associated with significant central and peripheral inflammation. This must be taken into consideration in planning future strategies to prevent CPSP., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: An increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades., Objectives: This study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years., Patients and Methods: The study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988-1994, 1995-2001, 2001-2006 and 2007-2012., Results: Within the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988-1994, 1995-2001, 2001-2006 and 2007-2012: 21%, 37%, 61% and 64%, respectively, p<0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007-2012: 98 %). During the study period increasingly more patients received multimodal therapy (13%, 85%, 72% and 84%, p<0.001), the overall rate of perioperative complications (70%, 88%, 73% and 56%, p<0.001) and perioperative mortality (16%, 18%, 8% and 2.5%, p<0.001) were significantly reduced, while the overall 5-year survival (12%, 34%, 41% and 62%, p<0.001) improved. An early tumor stage (p=0.002), N0 status (p<0.001) and histological type of adenocarcinoma (p=0.011) were identified as independent predictors of improved survival., Conclusion: During the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.

During the past decade, many surgeons have focused their interest on the development and improvement of minimally invasive techniques for aortic valve replacement. Although the minimally invasive approaches for the treatment of mitral valve disease have been standardized, the preferred route for aortic valve replacement remains a matter of debate. Access through a right minithoracotomy avoids opening the sternum; however, it requires a greater surgical ability and a learning period, even for experienced surgeons. This enhances the role of sutureless prostheses because these devices are associated with easier placement, excellent hemodynamic performance, and acceptable rates of pacemaker implantation and paravalvular leak. Herein, we report a series of 10 consecutive patients who received an EDWARDS INTUITY rapid deployment valve (Edwards Lifesciences, Irvine, CA USA) by a right minithoracotomy.

Objectives: To prevent urinary retention, urinary catheters commonly are removed only after thoracic epidural discontinuation after thoracotomy. However, prolonged catheterization increases the risk of infection. The purpose of this study was to determine the rates of urinary retention and catheter-associated infection after early catheter removal., Design: This study described a prospective trial instituting an early urinary catheter removal protocol compared with a historic control group of patients., Setting: The protocol was instituted at a single, academic thoracic surgery unit., Participants: The study group was comprised of patients undergoing surgery requiring thoracotomy who received an intraoperative epidural for postoperative pain control., Interventions: An early urinary catheter removal protocol was instituted prospectively, with all catheters removed on or before postoperative day 2. Urinary retention was determined by bladder ultrasound and treated with recatheterization., Measurements and Main Results: The primary outcomes were urinary retention rate, defined as bladder volume>400 mL, and urinary tract infection rate. Results were compared with a retrospective cohort of 210 consecutive patients who underwent surgery before protocol initiation. Among the 101 prospectively enrolled patients, urinary retention rate was higher (26.7% v 12.4%, p = 0.003), while urinary tract infection rate improved moderately (1% v 3.8%, p = 0.280)., Conclusions: Early removal of urinary catheters with thoracic epidurals in place is associated with a high incidence of urinary retention. However, an early catheter removal protocol may play a role in a multifaceted approach to reducing the incidence of catheter-associated urinary tract infections., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: This study explored the modern treatment of thoracic empyema. We evaluated outcomes of various operative approaches in both academic and nonacademic institutions., Methods: We queried the Society of Thoracic Surgeons National Database for patients undergoing thoracic procedures with a primary diagnosis of empyema between 2009 and 2011. We compared treatment outcomes of patients having procedures at academic (n = 1101, 28.3%) and nonacademic (n = 2790, 71.7%) medical centers., Results: Empyema treatments recorded in the database included tube thoracostomy (n = 325, 8.4%), video-assisted thoracic surgery (n = 1992, 51.2%), and thoracotomy (n = 1574, 40.5%). Academic centers had higher rates of treatment by thoracostomy (13.8% vs. 6.2%), similar treatment rates of video-assisted thoracic surgery (49.9% vs. 51.7%), and lower rates of thoracotomy (36.3% vs. 42.1%) compared to nonacademic centers (p < 0.001). Academic centers treated almost twice as many complicated empyemas with fistulas (11.4% vs. 6.5%, p < 0.001). Postoperative length of stay was higher in the academic centers (interquartile range 5-13 vs. 4-11 days, p = 0.001), while mechanical ventilation >48 h was more frequent in the nonacademic centers (7.6% vs. 4.4%, p = 0.013)., Conclusion: Surgeons in both academic and nonacademic centers use selective surgical approaches for treatment of thoracic empyema, depending on the clinical condition of the patient, with fairly equivalent results across all procedure types.

The care of patients with thoracic injuries has undergone monumental change over the past 25 years. Advances in technology have driven improvements in care, with obvious benefits to patients. In many instances, new or "disruptive" technologies have unexpectedly displaced previously established standards for the diagnosis and treatment of these potentially devastating injuries. Examples of disruptive technology include the use of ultrasound technology for the diagnosis of cardiac tamponade and pneumothorax; thoracoscopic techniques instead of thoracotomy, pulmonary tractotomy, and stapled lung resection; endovascular repair of thoracic aortic injury; operative fixation of flail chest; and the enhanced availability of extracorporeal lung support for severe respiratory failure. Surgeons must be prepared to recognize the benefits, and limits, of novel technologies and incorporate these methods into day-to-day treatment protocols., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose of Review: Survival from traumatic cardiac arrest is associated with a very high mortality despite aggressive resuscitation including an Emergency Department thoracotomy (EDT). Novel salvage techniques are needed to improve these outcomes., Recent Findings: More aggressive out-of-hospital interventions, such as chest decompression or thoracotomy by emergency physicians or anesthesiologists, seem feasible and show some promise for improving outcomes. For trauma patients who suffer severe respiratory failure or refractory cardiac arrest, there seems to be an increasing role for the use of extracorporeal life support (ECLS), utilizing heparin-bonded systems to avoid systemic anticoagulation. The development of exposure hypothermia is associated with poor outcomes in trauma patients, but preclinical studies have consistently demonstrated that mild, therapeutic hypothermia (34 °C) improves survival from severe hemorrhagic shock. Sufficient data exist to justify a clinical trial. For patients who suffer a cardiac arrest refractory to EDT, induction of emergency preservation and resuscitation by rapid cooling to a tympanic membrane temperature of 10 °C may preserve vital organs long enough to allow surgical hemostasis, followed by resuscitation with cardiopulmonary bypass., Summary: Salvage techniques, such as earlier thoracotomy, ECLS, and hypothermia, may allow survival from otherwise lethal injuries.

Background: Learning curves are vigorously discussed and viewed as a negative aspect of adopting new procedures. However, very few publications have methodically examined learning curves in cardiac surgery, which could lead to a better understanding and a more meaningful discussion of their consequences. The purpose of this study was to assess the learning process involved in the performance of minimally invasive surgery of the mitral valve using data from a large, single-center experience., Methods and Results: All mitral (including tricuspid, or atrial fibrillation ablation) operations performed over a 17-year period through a right lateral mini-thoracotomy with peripheral cannulation for cardiopulmonary bypass (n=3907) were analyzed. Data were obtained from a prospective database. Individual learning curves for operation time and complication rates (using sequential probability cumulative sum failure analysis) and average results were calculated. A total of 3895 operations by 17 surgeons performing their first minimally invasive surgery of the mitral valve operation at our institution could be evaluated. The typical number of operations to overcome the learning curve was between 75 and 125. Furthermore, >1 such operation per week was necessary to maintain good results. Individual learning curves varied markedly, proving the need for good monitoring or mentoring in the initial phase., Conclusions: A true learning curve exists for minimally invasive surgery of the mitral valve. Although the number of operations required to overcome the learning curve is substantial, marked variation exists between individual surgeons. Such information could be very helpful in structuring future training and maintenance of competence programs for this kind of surgery.

Penetrating chest trauma can be used as an indicator of violence in the country. We aimed to look at the changes in its incidence and management at a major trauma centre in the country. We also wanted to look at any effect of prehospital time on surgical intervention and outcome of the victim. In this retrospective descriptive study, we observed the presentation and management of 191 penetrating chest injury patients at a level II trauma hospital in Pakistan in the last 20 years. The study sample was divided into two groups: Group 1, 1988-1998 and Group 2, 1999-2009. No significant change in incidence of trauma was observed between the two groups. The delay in the time between event and arrival showed an increase in the number of surgical procedures performed. Also the number of thoracotomies performed went up significantly in the second decade from 5.7 to 16.5% with a P<0.05. Six (3.1%) mortality cases were observed in 20 years. It was seen that the greater the prehospital time, the greater the chances of surgery. Also seen was the increase in mortality as critical cases could make it to the hospital alive in recent times due to improved transportation services.

Background: The aim of our study was the analysis of long-term developments in the surgical therapy for esophageal carcinoma at our hospital over a period of 20 years with a differentiated view on the two predominant histological tumour types., Patients and Methods: Between September 1985 and September 2005, esophageal resections were performed in 470 patients at our clinic on account of a malignant tumour of the esophagus. The abdomino-thoracic resection with abdominal and extended mediastinal lymph node dissection as well as intrathoracic anastomosis was the standard treatment in the case of squamous cell carcinoma, whereas in adenocarcinoma a transhiatal resection with abdominal and dorsal mediastinal lymphadenectomy and cervical esophagogastrostomy was carried out. For analysis of the development, the study period of 20 years was divided into two intervals: interval 1 from 9 / 1985 to 9 / 1995, and interval 2 from 10 / 1995 to 9 / 2005., Results: Both tumour entities displayed in the last interval (10 / 1995 to 9 / 2005) significantly earlier tumour stages. A proportionally identical amount of transhiatal resections for squamous cell carcinoma was found in both intervals, whereas the transhiatal procedures for adenocarcinoma increased in the last decade (3.6 % in the period between 9 / 1985 and 9 / 1995, as compared with 23.6 % between 10 / 1995 and 9 / 2005) (p < 0.05). While the overall prognosis for squamous cell carcinoma did not significantly differ in the two decades (p = 0.2040), patients with adenocarcinoma were found to have a significantly improved long-term survival (log-rank test: p = 0.0365) in the second decade. The prognosis for adenocarcinoma, therefore, could be improved in the course of time with a 3-year survival rate of finally 40 % (as compared with 17.5 % in the first decade), and a 5-year survival rate of 25 % (as compared with 15 %)., Conclusion: Surgical therapy for esophageal carcinoma has undergone distinct changes over the past 20 years. These are mainly due to epidemiological and diagnostic aspects, an improved selection of patients, whereby the operative procedure is adapted to the tumour stage and the operative risk for the patient. Especially with adenocarcinoma of the esophagus, these changes have led to a significantly more favourable long-term prognosis.

The surgical treatment of the lung was developed primarily for pulmonary tuberculosis until the 1960s but was used for primary lung cancer in the 1970s. The incidence of lung cancer will increase in the next 30 years worldwide, and the annual incidence of lung cancer in Japan is expected to increase to about 150,000 by 2015. Over the past 50 years, pulmonologists have performed clinicopathological studies in an attempt to prevent lung cancer. Early detection became possible with such studies; as a result, the rate of detection of lung cancer at stage I has increased. Furthermore, the frequencies of histological detection of peripheral squamous cell carcinoma and adenocarcinoma have increased. Thoracic surgeons have developed techniques, such as limited pulmonary resection, and have established a minimally invasive approach to the thorax. These successes were followed by the development of thoracoscopic surgery. However, minimally invasive surgery that allows for functional preservation has not yet been developed. Future investigations and the refinement of technologies are needed.

Background: Damage control surgery (DCS) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. The objective of this study was to see whether advances in critical care, DCS, and recognition of abdominal compartment syndrome have improved survival from penetrating abdominal injury (PAI)., Methods: The care of 250 consecutive patients requiring laparotomy for PAI (1997-2000) was reviewed retrospectively. Organ injury patterns, survival, and use of DCS and its impact on outcome were compared with a similar experience reported in 1988., Results: Two hundred fifty patients had a positive laparotomy for PAI. Twenty-seven (10.8%) required abdominal packing and 45 (17.9%) did not have fascial closure. Seven (2.8%) required emergency department thoracotomy and 21 (8.4%) required operating room thoracotomy. Two hundred seventeen (86.8%) survived overall. Small bowel (47.2%), colon (36.4%), and liver (34.4%) were most often injured. Mortality was associated with the number of organs injured (odds ratio, 1.98; 95% confidence interval, 1.65-2.37; p < 0.001). Vascular injury was a risk factor for mortality (p < 0.001), as was need for DCS (p < 0.001), emergency department thoracotomy (p < 0.001), and operating room thoracotomy (p < 0.001). Seventy-nine percent of deaths occurred within 24 hours from refractory hemorrhagic shock. DCS was used in 17.9% (n = 45) versus 7.0% (n = 21) in 1988, with a higher survival rate (73.3% vs. 23.8%, p < 0.001). DCS was associated with significant morbidity including sepsis (42.4%, p < 0.001), intra-abdominal abscess (18.2%, p = 0.009), and gastrointestinal fistula (18.2%, p < 0.001)., Conclusion: Penetrating abdominal organ injury patterns and survival from PAI have remained similar over the past decade. Death from refractory hemorrhagic shock in the first 24 hours remains the most common cause of mortality. DCS and the open abdomen are being used more frequently with improved survival but result in significant morbidity.

Rib harvested during thoracotomy can be effectively used for anterior column reconstruction. An innovative technique is described to convert multiple individual rib segments into a robust single anterior column reconstruction graft using cortical screws.

The transthoracic approach to herniated thoracic discs is an important procedure in the management of these uncommonly encountered lesions. Whereas posterior and posterolateral microsurgical approaches and thoracoscopic procedures have been widely advocated in the recent neurosurgical literature, the transthoracic operation continues to offer significant advantages in appropriately selected cases. The authors discuss the preoperative considerations, relevant anatomical structures, and surgical technique.

Background: The geographic distribution of trauma centers results in a significant number of children being treated in adult centers. The emphasis on nonoperative management of pediatric blunt trauma has heightened concern that in adult trauma centers, an aggressive operative approach will continue to be used. We hypothesized that pediatric commitment at a Level I trauma center results in appropriate nonoperative care of injured children as established by regional pediatric trauma centers., Methods: The records of 1,792 consecutively treated children admitted to the trauma service during a 6-year period (January of 1990 to December of 1995) were reviewed. Patients were stratified into one of three age groups: 0 to 5, 6 to 11, and 12 to 17 years of age., Results: Mean age of the study patients was 10.0 +/- 0.1 years, 1,147 were boys (64%), and their mean Injury Severity Score was 7.3 +/- 0.3. The injury mechanism was blunt in 1,550 (87%) and 132 (7%) required laparotomy. In the 0- to 5-year-old blunt mechanism group, 6% underwent laparotomy or thoracotomy from 1990 to 1992. In comparison, only 1% of this age group had a laparotomy from 1993 to 1995 (p < 0.05, Fisher's exact test). A similar trend was found in the 6- to 11-year-old children after blunt injury (4% laparotomy rate from 1990 to 1992; 2% from 1993-1995)., Conclusion: There has been a declining trend in the operative management of blunt pediatric trauma, especially in children less than 6 years old, whereas the operative management of penetrating injuries has remained stable. These data confirm that pediatric commitment in a Level I trauma center results in nonoperative treatment of injured children commensurate with that established in regional pediatric trauma centers.

The optimal management of paediatric empyema thoracis remains controversial. The objective of the study was to analyse evolving experience in clinical presentation, management, outcome and factors contributing to adverse morbidity in thoracic empyema. Forty-seven patients presenting to a paediatric surgical centre were studied in three consecutive 6-y periods during 1980-97 to compare any change in the pattern of disease influencing diagnosis and management. Patients were categorized into two treatment groups: (i) conservative management (antibiotics and/or tube thoracostomy), (ii) thoracotomy. The median duration of illness prior to hospital admission was 10 d (range 1-42 d). Ultrasound was increasingly utilized in the diagnosis and staging of empyema and played an important role in directing definitive management. The presence of loculated pleural fluid determined the need for thoracotomy. Sixteen of 20 patients (80%) who were initially treated with thoracocentesis or tube thoracostomy eventually needed thoracotomy. There was a positive shift in management towards early thoracotomy resulting in prompt symptomatic recovery. Significant complications were noted in seven children who had delayed thoracotomy. These included recurrent empyema with lung abscess (n = 2), scoliosis (n = 2), restrictive lung disease (n = 1), bronchopleural fistula (n = 1) and sympathetic pericardial effusion (n = 1). An unfavourable experience with delayed thoracotomy during the study period has led us to adopt a more aggressive early operative approach to empyema thoracis. The decision to undertake thoracotomy has been influenced by the ultrasound findings of organized loculated pleural fluid. Delayed surgery was associated with adverse outcome. Whilst fibrinolytics and thoracoscopy may provide attractive options for early empyema, thoracotomy can hasten patient recovery regardless of the stage of disease. Prospective randomized trials are required to assess the ideal therapy for childhood empyema.

Background: The advent of videothoracoscopy may restrict the indications for thoracotomy in blunt chest trauma., Methods: We retrospectively compared two groups of patients with blunt chest trauma observed in consecutive periods, before and after the advent of videothoracoscopy, 989 patients from 1989 to 1993 and 908 patients from 1994 to 1998., Results: During the first period, 38 thoracotomies were performed; but in 8 instances (21%), no major injuries were found. In the second period, 36 videothoracoscopies were performed to repair the lung (n = 5) or diaphragm (n = 5), to evacuate clots (n = 4), pericardial effusion (n = 3), and empyema (n = 2). Six procedures were converted and 11 findings were negative for lesions. Only nine intentional thoracotomies were performed, and significant lesions were found in each case., Conclusion: Videothoracoscopy has reduced the number of thoracotomies performed. Thoracotomy can be limited to massive bleeding with hemodynamic instability, major air leak, radiologic evidence of mediastinal enlargement or diaphragmatic rupture, or major anterolateral flail chest.

A prospective study documented all minimally invasive operations performed in the department of thoracic surgery between 1992 and 1996. The most frequent indications were: lung biopsy (n = 181, 30.9%), coin lesions of unknown origin (n = 179; 30.5%), pneumothoraces (n = 133; 22.7%), pleura effusions (n = 19; 3.2%), and pleura empyema (n = 13; 2.2%). The majority (82.6%) of the minimally invasive procedures were completed without conversion; in 6.0% an extension (< 5 cm) of one of the trocar incisions was necessary and in 11.5% an anterolateral thoracotomy. It is demonstrated that a wide spectrum of thoracic operations can be performed by the minimally invasive approach.