Jared L. Antevil

Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come.

BACKGROUND Although the traditional method of diagnosing spine fractures (SF) has been plain radiography, Spiral Computed Tomography (SCT) is being used with increasing frequency. Our institution adopted SCT as the primary modality for the diagnosis of SF. The purpose of this study was to determine whether SCT scan can be used as a stand-alone diagnostic modality in the evaluation of SF. METHODS Retrospective review of all blunt trauma patients over a two year period (1/01-12/02). Patients with neck pain, back pain, or spine tenderness underwent SCT of the symptomatic region. Patients who were unconscious or intoxicated underwent screening SCT of the entire spine. SCT was performed using 5 mm axial cuts with three-dimensional reconstructions in sagittal and coronal planes. Patients with a discharge diagnosis of cervical, thoracic, or lumbar SF were identified from the trauma registry by ICD-9 codes. RESULTS There were 3,537 blunt trauma patients evaluated, with 236 (7%) sustaining a cervical, thoracic, or lumbar SF. Forty-five patients (19%) sustained a SF in more than one anatomic region. SCT missed SF in two patients. The cervical SF missed by SCT was a compression fracture identified by magnetic resonance imaging and was treated with a rigid collar. The thoracic SF missed by SCT was also a compression fracture identified on plain radiographs and required no treatment. CONCLUSIONS SCT of the spine identified 99.3% of all fractures of the cervical, thoracic, and lumbar spine, and those missed by SCT required minimal or no treatment. SCT is a sensitive diagnostic test for the identification of SF. Routine plain radiographs of the spine are not necessary in the evaluation of blunt trauma patients.

Small catheter tube thoracostomy: effective in managing chest trauma in stable patients.

BACKGROUND Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. METHODS Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. RESULTS There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. CONCLUSION SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

Laparoscopic accessory splenectomy with intraoperative gamma probe localization for recurrent idiopathic thrombocytopenic purpura.

Laparoscopic excision of retained splenic tissue has been described as a treatment of recurrent hematologic disease after formal splenectomy. It is associated with a shorter hospital stay, more rapid recovery, and lower or equivalent morbidity compared with open surgery. However, intraoperative identification of residual splenic tissue remains difficult, particularly when preoperative computed tomography or magnetic resonance imaging results are unremarkable. It has been suggested that the laparoscopic approach has a lower success rate due to the loss of tactile feedback. We report a case of successful laparoscopic excision of retained splenic tissue using technetium sulfur colloid injection and intraoperative gamma probe localization in a patient with recurrent idiopathic thrombocytopenic purpura, 12 years after open splenectomy. This represents the first report of this intraoperative adjunctive measure for the laparoscopic identification and excision of functional accessory splenic tissue.

Abdominal computed tomography for postoperative abscess: is it useful during the first week?

While classic teaching dictates computed tomography (CT) for postoperative abdominal or pelvic abscess in the first week is of low yield, little evidence supports intentional delays in imaging for suspected abscess. This retrospective review examined all CT scans obtained for clinical suspicion of abscess between 3 and 30 days after abdominal or pelvic operation over a 3-year period. Scans were grouped into those obtained between 3 and 7 days after surgery (EARLY) and those obtained after day 7 (LATE). Diagnostic yield was compared between EARLY and LATE groups. Of 262 CT examinations (EARLY, n=106; LATE, n=156), 71 studies (27%) demonstrated abscess. There was no significant difference in the diagnostic yield of CT for abscess between EARLY and LATE groups (23% [24 of 106] versus 30% [47 of 156], P=0.18). Of patients with an abscess, 63% (45 of 71) underwent percutaneous or operative drainage (EARLY 75% [18 of 24], LATE 57% [27 of 47], P=0.15). Abdominal CT for postoperative abscess can be expected to be diagnostic in a substantial proportion of cases in the first week, the majority of which lead to percutaneous or operative drainage. Postoperative CT for intra-abdominal abscess should be obtained as clinically indicated, regardless of interval from surgery.

Safe and Rapid Laparoscopic Access—a New Approach

Despite numerous recent technical advances in minimally invasive surgical technique, the potential exists for serious morbidity during initial laparoscopic access. Safe access depends on adhering to well-recognized principles of trocar insertion, knowledge of abdominal anatomy, and recognition of hazards imposed by previous surgery. Applying these principles, we describe a safe, rapid, and cost-effective technique for laparoscopic access using readily available instruments. This technique emphasizes identification and incision of the point at which the midline abdominal fascia is fused with the base of the umbilicus, and the importance of the application of countertraction directly at the point of insertion. This method allows penetration under direct vision with minimal controlled axial force, and without the requirement for fascial sutures or other cumbersome aspects of the traditional open technique. While previous reports describe techniques for laparoscopic access entry based on similar anatomic and surgical principles, we describe an alternative method not yet discussed in the surgical literature.

Use of a hybrid operating room to diagnose and treat delayed coronary spasm after mitral valve repair

From the Vanderbilt Heart and Vascular Institute, Nashville, Tenn. Disclosures: None. Received for publication June 10, 2009; revisions received July 14, 2009; accepted for publication July 31, 2009; available ahead of print Sept 27, 2009. Address for reprints: John G. Byrne, MD, Vanderbilt University Medical Center, Nashville, TN 37232-8802 (E-mail: john.byrne@vanderbilt.edu). J Thorac Cardiovasc Surg 2010;140:e25-7 0022-5223/

Special considerations of military cardiothoracic surgeons

36.00 Copyright 2010 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2009.07.074

Care for the Postoperative Cardiac Surgery Patient

From the Department of Surgery–Cardiothoracic, San AntonioMilitary Medical Center, Joint Base; Department of Surgery–Cardiothoracic, Audie L. Murphy Veterans Affairs Medical Center, San Antonio, Tex; Heart Lung Vascular Center, David Grant Medical Center, Travis Air Force Base; Section of General Thoracic Surgery, University of California, Davis, Medical Center, Sacramento, Calif; and Department of Surgery–Cardiothoracic, Walter Reed National Military Medical Center, Bethesda, Md. This editorial is an independent expression of the authors and does not represent the view of the US Government, the US Army, the US Air Force, or the US Navy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Oct 15, 2015; revisions received March 22, 2016; accepted for publication April 28, 2016; available ahead of print June 14, 2016. Address for reprints: LTC Bryan S. Helsel, MD, Department of Surgery–Cardiothoracic, San Antonio Military Medical Center, 3551 Roger Brooke Dr, San Antonio, TX 78234 (E-mail: deltaguns@aol.com). J Thorac Cardiovasc Surg 2016;152:664-6 0022-5223/

Wartime Vascular Injury

0.00 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.04.089 Patriotic American eagle.

Emergency Resuscitative Thoracotomy in the Combat or Operational Environment

The care for patients after cardiac surgery should begin with standardized pathways, with the goal of structured care criteria rooted in best available evidence. Such pathways are only a starting place, however, as every patient’s procedure and course is unique. Optimal care relies on a team that is able to recognize deviations from normal physiology and recovery in the context of a given condition and procedure and that institutes early and appropriate action when faced with potential complications.