Pyng Jing Lin

Video-assisted thoracic surgery in treatment of chest trauma.

Although the indications for video-assisted thoracic surgery (VATS) have expanded rapidly, especially in the areas of therapeutic and operative procedures, its role in the definite surgical treatment of chest trauma is not clear. From July 1994 to December 1995, 56 patients with hemothorax or posthemothorax complications resulting from chest trauma received thoracic surgery. Their ages ranged from 17 to 71 years. Mechanisms of injury included penetrating (n = 23) and blunt injury (n = 33). VATS was successfully applied in 50 patients; six patients with cardiovascular injuries (n = 4) or minor chest wall lacerations (n = 2) did not receive VATS. All patients who received VATS survived, with no morbidity. Twelve of the 50 patients treated with VATS would have otherwise had to undergo thoracotomy. Our results indicate that VATS can be safely used in hemodynamically stable patients with no cardiovascular or great vessel injury, sparing many patients the pain and morbidity associated with thoracotomy. Additionally, use of VATS may reduce the likelihood of posthemothorax complications by allowing early direct inspection of the chest wall, because VATS has a lower associated risk and can be performed with a lower index of suspicion than can standard thoracotomy.

Blunt traumatic cardiac rupture: therapeutic options and outcomes.

INTRODUCTION Cardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same. METHODS This is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome. RESULTS The study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18+/-5.7 (range: 25-43), 6.267+/-1.684 (range: 2.628-7.841), and 72.4+/-25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n=4), right atrial auricle (n=1), right ventricle (n=4), left ventricular contusion (n=1), and diffuse endomyocardial dissection over the right and left ventricles (n=1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state. CONCLUSIONS We proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.

Extracorporeal life support to terminate refractory ventricular tachycardia.

Objective:Extracorporeal life support (ECLS) has been applied successfully to patients with cardiopulmonary failure in extreme situations. Refractory ventricular tachycardia has high mortality and morbidity rates if not terminated in time. This study describes our preliminary experiences in using ECLS to treat patients with refractory ventricular tachycardia. Design:Retrospective chart review. Setting:Hospital. Patients:Eleven patients suffering from ventricular tachycardia refractory to antiarrhythmia agents and cardioversion attempts. Interventions:From January 2002 to December 2004, 11 patients suffering from ventricular tachycardia refractory to antiarrhythmia agents and cardioversion attempts were treated with ECLS. Mean patient age was 31 ± 21 yrs (range, 3–69 yrs). The triggering events were acute myocarditis (n = 8), coronary artery spasm (n = 1), and hypoxemia secondary to acute respiratory distress syndrome (n = 2). Nine (82%) patients received venoarterial mode support and the remaining two (18%) were supported with venovenous mode to correct hypoxemia. Pump flow was first maximized (mean, 3800 ± 1100 mL/min) to unload the heart, and an intra-aortic balloon pump was used to deal with the increased afterload (n = 8). Measurements and Main Results:Mean ventricular tachycardia duration before ECLS was 50 ± 16 mins (range, 20–75 mins) and soon converted to a sinus rhythm following ECLS deployment, including four patients who experienced spontaneous recovery without attempted cardioversion, in a mean of 7.4 mins (range, 1–20 mins). Four patients required temporary pacing but none needed a permanent pacemaker after recovery. Mean duration of ECLS support was 119 ± 69 hrs (range, 12–250 hrs). We excluded one patient who had permanent brain injury and another who succumbed to multiple organ failure. Nine (82%) patients were weaned and discharged with normal cardiac function. No recurrent ventricular tachycardia attack but one recurrent cardiomyopathy (ejection fraction = 15%) was reported during a mean 42-month follow-up. Conclusions:Using ECLS to terminate refractory ventricular tachycardia proved effective for selected patients when conventional therapeutic options were exhausted. Early deployment of ECLS to prevent secondary organ injury, maintain sufficient cardiac unloading, and avoid complications during ECLS support was central to successful outcomes.

Pulmonary embolectomy in high-risk acute pulmonary embolism: the effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support.

OBJECTIVES To investigate the effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support (ECLS) in high-risk acute pulmonary embolism (aPE) treated with pulmonary embolectomy. MATERIALS AND METHODS This retrospective study included 25 consecutive patients of aPE treated with pulmonary embolectomy in a single institution between June 2005 and July 2012. All patients had high-risk aPE identified by computed tomographic angiography and were not suitable for thrombolytic therapy. High-risk aPE here was defined as aPE with (1) hemodynamic instability, (2) a pulmonary artery obstruction index (PAOI)≥0.5, (3) a diameter ratio of right ventricle-to-left ventricle (RV-to-LV)≥1.0, or (4) right heart thrombi. Once the eligibility was confirmed, a 3-staged therapeutic algorithm was adopted to perform an aggressive preoperative resuscitation, an expeditious pulmonary embolectomy with multidisciplinary postoperative care, and a thorough surveillance for recurrence. RESULTS Among the 25 patients, 24 had a PAOI≥0.5 and 23 had a RV-to-LV diameter ratio≥1.0. Four patients had right heart thrombi. Sixteen patients developed preoperative instability requiring inotropic and/or mechanical support. Eight in the 16 had a preoperative cardiac arrest (CA) and six of these were bridged to surgery on ECLS. Three in the 6 patients weaned ECLS after surgery and survived to discharge. The overall in-hospital mortality was 20% (n=5). A preoperative CA (Odds ratio [OR]: 16, 95% confidence interval [CI]: 1.4-185.4, p=0.027, c-index: 0.80) and a postoperative requirement of ECLS (OR: 36, 95% CI: 2.1-501.3, p=0.008, c-index: 0.85) was the pre- and postoperative predictor of in-hospital mortality. No late deaths or re-admission for recurrence were found during a median follow-up of 19 months (interquartile range: 8-29). CONCLUSION Pulmonary embolectomy was an effective intervention of high-risk aPE. However, the occurrence of preoperative CA still carried a high mortality in spite of the assistance of ECLS.

Extracorporeal life support in post-traumatic respiratory distress patients

BACKGROUND Extracorporeal life support (ECLS) has been applied successfully to patients with acute cardiopulmonary failure. However, ECLS remains controversial for traumatized patients who are prone to bleeding. PATIENTS AND METHODS From March 2004 to October 2007, nine patients with post-traumatic respiratory distress refractory to ventilator support were treated with ECLS. Mean patient age was 35.1+/-9.7 (range, 18-47) years, average injury severity score (ISS) was 44.56+/-4.93 (range, 35-50), and Sequential Organ Failure Assessment score (SOFA) score was 12.1+/-3.67 (range, 7-16). Before ECLS, all patients had received thoracic interventions, including four lung resections, with a mean PaO(2) of 49.04+/-9.82 (range, 31-64) mmHg and PaCO(2) of 66.4+/-15.72 (range, 45-86) mmHg. Seven patients were supported in standard veno-venous mode, and the other two were initially supported in veno-arterial mode due to hemodynamic instability. RESULTS Median interval from trauma to ECLS was 33 (range, 4-384) h, and median duration of ECLS was 145 (range, 69-456) h. Six (66.7%) patients received additional surgeries during ECLS. One died of sepsis from occult colon rupture and the other of acute liver failure, 6 and 13 days respectively after trauma. Seven (77.8%) patients were weaned and discharged. CONCLUSIONS Using ECLS to resuscitate traumatic respiratory distress proved to be safe and effective when conventional therapies had been exhausted. Early deployment of ECLS to preserve systemic organ perfusion, aggressive treatment of coexisting injuries and tailored anticoagulation protocols are crucial to a successful outcome.

Treatment of esophageal perforation in a referral center in taiwan.

PurposeThe high mortality associated with esophageal perforation can be reduced by aggressive surgery and good critical care. We report our experience of treating esophageal perforation in a clinic in Taiwan.MethodsThe subjects were 28 patients who underwent surgery for a benign esophageal perforation.ResultsThe esophageal perforation was iatrogenic in 11 patients, spontaneous in 8, and caused by foreign body injury in 9. Most (22/28) of the patients were seen longer than 24 h after perforation, and 77% had empyema preoperatively. The perforation was located in the cervical area in 5 patients and in the thoracic esophagus in 23. We performed primary repair in 24 patients, esophagectomy in 3, and drainage in 1. Leakage occurred after primary repair in ten (41%) patients, resulting in one death, and two patients died of other diseases. Postoperative leakage prolonged the hospital stay but had no impact on mortality. Overall survival was 90%. Univariate analysis revealed that age, timing of treatment, and cause and location of the perforation influenced outcome, but multivariate analysis failed to identify a predictor of mortality.ConclusionsEarly diagnosis and intervention are crucial to prevent morbidity and mortality in patients with esophageal perforation. Primary repair is feasible even if the diagnosis is delayed.

Venoarterial extracorporeal life support in post-traumatic shock and cardiac arrest: lessons learned

ObjectivesVenoarterial extracorporeal life support (VA-ECLS) is an effective support of acute hemodynamic collapse caused by miscellaneous diseases. However, using VA-ECLS for post-traumatic shock is controversial and may induce a disastrous hemorrhage. To investigate the feasibility of using VA-ECLS to treat post-traumatic shock or cardiac arrest (CA), a single-center experience of VA-ECLS in traumatology was reported.Materials and methodsThis retrospective study included nine patients [median age: 37 years, interquartile range (IQR): 26.5-46] with post-traumatic shock/CA who were treated with VA-ECLS in a single institution between November 2003 and October 2012. The causes of trauma were high-voltage electrocution (n = 1), penetrating chest trauma (n = 1), and blunt chest or poly-trauma (n = 7). Medians of the injury severity score and the maximal chest abbreviated injury scale were 34 (IQR: 15.5-41) and 4 (IQR: 3-4), respectively. All patients received peripheral VA-ECLS without heparin infusion for at least 24 hours.ResultsThe median time from arrival at our emergency department (ED) to VA-ECLS was 6 h (IQR: 4-47.5). The median duration of VA-ECLS was 91 h (IQR: 43-187) with a duration < 24 h in 2 patients. Among the 9 patients, 5 received VA-ECLS to treat the post-traumatic shock/CA presenting during (n = 2) or following (n = 3) damage-control surgeries for initial trauma, and another 4 patients were supported for non-surgical complications associated with initial trauma. VA-ECLS was terminated in 2 non-survivors owing to uncontrolled hemothorax or retroperitoneal hemorrhage. Three patients survived to hospital discharge. All of them received damage-control surgeries for initial trauma and experienced a complicated hospitalization after weaning off VA-ECLS.ConclusionUsing VA-ECLS to treat post-traumatic shock/CA is challenging and requires multidisciplinary expertise.

Traumatic pericardial effusion: Impact of diagnostic and surgical approaches

INTRODUCTION In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion. PATIENTS AND METHODS Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center. RESULTS Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome. CONCLUSIONS Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.

Endothelium-dependent relaxation of canine pulmonary artery after prolonged lung graft preservation in University of Wisconsin solution: role of l-arginine supplementation

BACKGROUND The University of Wisconsin (UW) solution has been demonstrated to enhance pulmonary allograft preservation. Endothelial nitric oxide (NO) production has been shown to be significantly impaired after ischemia and reperfusion (I/R) injury. The present experiments aimed to determine the protective effects of pulmonary endothelium-dependent function by using supplemental NO in University of Wisconsin (UW) solution following prolonged lung graft preservation. METHODS Thirty-six healthy mongrel dogs underwent thoracotomy to expose the left lung. In addition to a group given UW solution (n = 4), 100 micromol/liter l-arginine, (n = 7), 100 micromol/liter N(G)-monomethyl-l-arginine (l-NMMA n = 7) and 1.0 micromol/liter 3-morpholinosydnonimine (SIN-1, n = 18 respectively, were added to UW solution, and infused from the aortic root and pulmonary artery to the pulmonary vein. The perfused lung was then allowed to inflate to its maximum volume for 24-hour oxygenated preservation in each supplemented condition of UW solution at 4 degrees C. In the SIN-1 group, the preservation period was further divided into 8 hours and 16 hours, respectively. Rings of the third-order pulmonary artery of the inflated lung were then suspended in organ chambers to measure isometric force. RESULTS Endothelium-dependent relaxation (EDR) to acetylcholine, adenosine diphosphate and sodium fluoride of the pulmonary rings in the l-arginine group was significantly preserved compared with UW-solution-only group. The l-NMMA group showed significant EDR impairment after 24-hour preservation compared with the UW solution group. Similar to the l-arginine group, the SIN-1 group showed significant EDR protection with 8-hour preservation, but not with 24-hour preservation. In contrast, EDR to calcium ionophore A23187 showed no EDR changes after 24-hour preservation in any of the supplemented groups. CONCLUSIONS Supplemental l-arginine in UW solution ameliorates impaired pulmonary EDR following prolonged lung preservation of up to 24 hours.

MINIMALLY INVASIVE CARDIAC SURGERY FOR INTRACARDIAC CONGENITAL LESIONS

OBJECTIVE Minimally invasive cardiac surgery has recently been applied to the correction of intracardiac lesions. This report reviews our experience of minimally invasive cardiac surgery in 119 patients with intracardiac congenital lesions. METHODS From October 1995 to April 1997, 119 patients (48 male and 71 female, aged 0.9-65 years old, 18.5+/-17.8) received elective minimally invasive cardiac surgery at Chang Gung Memorial Hospital, Taipei, Taiwan for repair of atrial septal defect (96 patients) or ventricular septal defect (23 patients). The operations were performed through right submammary incision (ASD) or left parasternal minithoracotomy (VSD), under femoro-femoral or femoro-atrial cardiopulmonary bypass with fibrillatory arrest. RESULTS All of the defects were repaired successfully. The bypass time was 25-125 min (46+/-18). The operation time was 1.5-5.2 h (2.8+/-0.8). The postoperative course was uneventful in all patients. Follow-up (1.0-18.2 months, mean 7.3) was complete, with no late deaths or residual shunt. All patients were found to be in NYHA functional class I or II. CONCLUSION Our experience demonstrate that minimally invasive cardiac surgery is a technically feasible, safe, and effective procedure in surgical correction of selective simple intracardiac congenital lesions, yielding good short-term results.