R. Alan Hall

Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis

BACKGROUND Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear. METHODS A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group. RESULTS One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 +/- 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 +/- 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 +/- 22 versus 36 +/- 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 +/- 9 versus 32 +/- 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms. CONCLUSIONS Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.

Complications of surgical Feeding jejunostomy in trauma patients

OBJECTIVE To determine the complication rate of feeding jejunostomy (FJ) performed as an adjunct to trauma celiotomy. METHODS Retrospective analysis of 222 patients from January of 1988 to May of 1998. RESULTS Thirty-seven total FJ-related complications occurred in 22 patients (10%). Major FJ-related complications occurred in nine patients (4%): two small bowel perforations, two small bowel volvuli with infarction, two intraperitoneal leaks, and three small bowel necroses. Patients suffering major FJ-related complications were similar to those without complications, except for the FJ type. Patients with major FJ-related complications were more likely to have had a Witzel tube jejunostomy than a needle catheter jejunostomy (p = 0.03). Three deaths were related to major FJ complications, for a FJ-related mortality rate of 1.4%. CONCLUSIONS FJ has a major complication rate of 4% in severely injured patients. Major complications occur more frequently with larger, Witzel-type tubes. Needle catheter jejunostomy appears to be a safer method of surgical jejunal access in trauma patients.

Endoscopic greater saphenous vein harvesting reduces the morbidity of coronary artery bypass surgery

BACKGROUND Most coronary artery bypass grafting (CABG) operations still involve the use of greater saphenous vein (GSV) for one or more grafts, even with the increasing use of arterial conduits for coronary revascularization. Wound complications from GSV harvesting are common, and sometimes severe. In order to reduce the morbidity of this procedure, we adopted a technique of endoscopic vein harvesting (EVH). EVH allows nearly complete harvest of the GSV, with excellent visualization, through minimal incisions. At our institution, a physicians assistant routinely performs EVH, usually while a cardiothoracic surgeon harvests an arterial conduit. In 1997, all GSV harvesting was performed by open technique. During a transition period in 1998 and 1999 we used several different endoscopic techniques. By the beginning of 2000, our technique of EVH was standardized and used routinely. METHODS To determine whether EVH reduced the morbidity associated with conventional open vein harvesting (OVH), we reviewed the charts of all patients having primary coronary artery bypass operations utilizing GSV during the years 1997 and 2000. RESULTS The two groups were comparable in risk factors for leg incision complications. The year 2000 EVH group had a marked reduction in the number of wound complications compared with the year 1997 OVH group (7.1% versus 26.1%, P < 0.00001). There were no significant differences between the two groups in total operative time (OVH 224 minutes, EVH 223 minutes, number of distal coronary anastomoses (OVH 3.38 +/- 0.90, EVH 3.38 +/- 0.94), or the rate of clinically apparent early graft failure. There was a significant increase in the use of sequential grafting techniques in the 2000 group (OVH 21.9%, EVH 43.6%, P < 0.00001). CONCLUSIONS EVH reduced the morbidity associated with GSV harvesting. EVH was associated with an increased use of sequential coronary grafting techniques. EVH does not prolong operative time when performed by experienced personnel. We believe EVH should become the standard of care.

Brain SPECT imaging and neuropsychological testing in coronary artery bypass patients

BACKGROUND Cognitive deficits appear frequently after cardiac operation. While the etiology remains unclear, alterations in cerebral perfusion during cardiopulmonary bypass may be causative. Single photon emission computed tomography (SPECT) scanning utilizes a radiopharmaceutical to provide images of cerebral perfusion. We proposed to study the cerebral circulation of patients during coronary artery bypass operation employing cardiopulmonary bypass. METHODS Thirty-five neurologically normal patients underwent preoperative SPECT brain scanning and neuropsychological testing. A second SPECT brain perfusion scan was obtained by administering the radioisotope during cardiopulmonary bypass, with subsequent scanning upon completion of the procedure. Postoperative neuropsychological testing was performed prior to discharge. RESULTS Fourteen (40%) of patients demonstrated significant neuropsychological decline. Patients who suffered cognitive impairment were no different in demographic, general health, or surgical variables. Patients who demonstrated neuropsychological decline had significantly poorer cerebral perfusion both at baseline and during operation. CONCLUSIONS Impaired cerebral perfusion at baseline may identify patients at risk for cognitive injury after cardiac operation. Alterations in cerebral perfusion during cardiopulmonary bypass is common, and may be a factor in neuropsychological deficits seen after cardiac operation.

Non-operative Management of Blunt Thoracic Aortic Injury

Traditionally, blunt thoracic aortic injury (BTAI) has been considered an absolute surgical emergency with immediate repair being the standard of care. This philosophy arose from Parmley’s 1958 seminal study documenting a death rate at the scene of up to 85%, and a subsequent mortality rate in non-operated survivors of 1% per hour for the first 48 hours. However, this report was a military autopsy study encompassing mechanisms of injury rarely witnessed in civilian trauma centers and reflecting the outcome of only the most severely injured who ultimately died. In the past decade, there has been a change in the management philosophy of BTAI with emphasis on blood pressure control and assessing the need for emergent repair against the risks of operation due to associated injuries or premorbid conditions.