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García AF, Rodríguez F, Sánchez Á, Caicedo-Holguín I, Gallego-Navarro C, Naranjo MP, Caicedo Y, Burbano D, Currea-Perdomo DF, Ordoñez CA, Puyana JC. Risk factors for posttraumatic empyema in diaphragmatic injuries. World J Emerg Surg 2022; 17:47. [PMID: 36100861 PMCID: PMC9472425 DOI: 10.1186/s13017-022-00453-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
Background Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center.
Methods This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors.
Results We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22–35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18–44) and 17 (10–27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77–23. 43), and visible contamination (OR 5.13, 95% IC 1.26–20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema.
Conclusion The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.
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Affiliation(s)
- Alberto Federico García
- Division of Trauma and Acute Care Surgery, Department of Surgery, Department of Intensive Care, Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia. .,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cali, Colombia. .,Department of General Surgery, Universidad Icesi, Cali, Colombia.
| | - Fernando Rodríguez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Department of Intensive Care, Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia.,Department of General Surgery, Universidad Icesi, Cali, Colombia
| | - Álvaro Sánchez
- Division of Thoracic Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia
| | - Isabella Caicedo-Holguín
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia
| | | | | | - Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia
| | - Daniela Burbano
- Department of General Surgery, Universidad de Caldas, Manizales, Colombia
| | | | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Department of Intensive Care, Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cali, Colombia.,Department of General Surgery, Universidad Icesi, Cali, Colombia
| | - Juan Carlos Puyana
- Professor of Surgery Director Global Health, Critical Care and Clinical Translational Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Shamim AA, Zuberi MM, Tran D, Fullum T. Laparoscopic reduction and repair of acute traumatic diaphragmatic hernia: A video review. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2020. [DOI: 10.1016/j.lers.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
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Selective Operative Management of Penetrating Chest Injuries. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0233-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sorour MA, Kassem MI, Ghazal AH, Azzam A, El-Khashab ESI, Shehata GM. Conservative approach in the management of isolated penetrating liver trauma. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Magdy A. Sorour
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Mohamed I. Kassem
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Abdel Hamid Ghazal
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Aymen Azzam
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | | | - Gihan M. Shehata
- Medical Informatics and Medical Statistics Department, Medical Research Institute , Alexandria University , Egypt
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Cardoso LF, Gonçalves MVC, Machado CJ, Resende V, Fernandes MP, Pastore-Neto M, Campanati RG, Reis GVOP. Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center. Rev Col Bras Cir 2017; 44:245-251. [PMID: 28767799 DOI: 10.1590/0100-69912017003004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/02/2017] [Indexed: 11/22/2022] Open
Abstract
Objective: to analyze the factors associated with death in patients with diaphragmatic injury treated at a trauma reference hospital. Methods: we conducted a retrospective study of patients with diaphragm injury attended at the Risoleta Tolentino Neves Hospital of the Federal University of Minas Gerais, between January 2010 and December 2014. We used The Collector® database of trauma records (MD, USA). We gathered data on demographics, location of the diaphragmatic lesion, site and number of associated lesions, type of therapeutic approach, complications and Injury Severity Score (ISS). The variable of interest was the occurrence of death. Results: we identified 103 patients and mortality was 16.5%. Penetrating lesions occurred in 98% of patients. Univariate analysis showed a mortality higher in patients whose treatment was non-operative, without closing of the defect (p=0.023), and lower in patients submitted to diaphragmatic suturing (p<0.001). The increase in the number of lesions was associated with an increase in mortality (p=0.048). In multivariate analysis, ISS>24 (OR=4.0, p=0.029) and diaphragmatic suturing (OR=0.76, p<0.001) were associated with mortality. Conclusion: The findings indicate that the traumatic rupture of the diaphragm rarely presents as an isolated lesion, being frequently associated with injuries of other organs, especially the liver and hollow viscera. Mortality was higher among those with ISS>24.
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Affiliation(s)
| | | | | | - Vivian Resende
- Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Chen B, Lu ZY, Zhang J, Zhu Z, Li XW. Curative effect of pleural lavage on open chest trauma caused by seawater immersion. Ann Saudi Med 2013; 33:277-81. [PMID: 23793432 PMCID: PMC6078528 DOI: 10.5144/0256-4947.2013.277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Open chest trauma with seawater immersion can lead systematic inflammatory response and multiple organ dysfunction syndromes (MODS). Early intervention of seawater immersion significantly decreases mortality. This study aims to explore the curative effect of pleural lavage in the treatment of open chest trauma caused by seawater immersion on dogs. DESIGN AND SETTINGS An in vivo experimental study was performed in healthy cross-breeding adult dogs (n=20). SUBJECTS AND METHODS A dog model of open chest trauma caused by seawater immersion was established. All experimental dogs were divided into control group and pleural lavage group, with 10 dogs in each group. In the control group, dogs were performed ventilator-assisted breathing, and thoracic tube was kept open for adequate chest water drainage; in the pleural lavage group, dogs were further injected with 0.9% sodium chloride (35 mL/kg) immediately into the right side of the chest after the pleural effusion was drained off. The internal environment, oxygen partial pressure, and pathological changes of the lung tissue were observed and recorded. RESULTS Following open chest trauma caused by seawater immersion, both groups showed obviously increased serum sodium and plasma osmolality and sharply decreased oxygen partial pressure. After treatment, the serum sodium and plasma osmolality decreased, whereas oxygen partial pressure increased in both groups. The pleural lavage group showed better improvement than the conventional treatment group. The pathological changes in the pleural group were lighter than in the conventional treatment group. CONCLUSION Compared with conventional treatment, repeated pleural lavage shows improved treatment in the correction of blood hypertonic state and hypoxemia in seawater-immersed open chest trauma.
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Affiliation(s)
- Bing Chen
- PLA 117 Hospital, Center of Cardiothoracic Surgery, No.14 Lingyin Road, Hangzhou, Zhejiang Province, China.
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Yang C, Yan J, Wang HY, Zhou LL, Zhou JY, Wang ZG, Jiang JX. Effects of bilateral adrenalectomy on the innate immune responses following trauma in rats. Injury 2011; 42:905-12. [PMID: 22081818 DOI: 10.1016/j.injury.2010.02.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The regulation of neuroendocrine hormones on the innate immune responses in trauma has not been fully understood. Previous studies have shown that the neuroendocrine hormones are important factors in their effects on immune parameters, depending on their concentration and timing instead of the simple suppressive effects. MATERIALS AND METHODS A total of 144 Sprague–Dawley rats were divided randomly into sham, pulmonary blast injury (BI) and adrenalectomy plus pulmonary BI groups. Bilateral adrenalectomy was performed on rats, which were then subjected to blast injury. Following this, peripheral leucocyte responsiveness to lipopolysaccharide (LPS) stimulation, phagocytosis activities of macrophages and bacteria translocation (BT) were examined. Tumour necrosis factor-a (TNF-a) levels and the expression levels of scavenger receptor (SR) A, CD14, Toll-like receptor (TLR) 4 and MD2 were assayed with enzyme-linked immunosorbent assay and reverse transcription-polymerase chain reaction, respectively. RESULTS In adrenalectomised rats after pulmonary BI, the number of peripheral leucocytes was increased and the phagocytosis of peritoneal and splenic macrophages was decreased as compared to the BI group. Simultaneously, the gut-derived BT and TNF-a secretion in lung tissues were elevated, whilst the LPS-stimulated TNF-a synthesis by peripheral leucocyte responsiveness was reduced. Furthermore, the mRNA levels of SR-A, CD14, TLR4 and MD2 in lung tissues of adrenalectomised rats decreased. Adrenalectomised rats showed enhancement of inflammatory responses and severe tissue injuries in trauma. CONCLUSIONS Release of adrenal hormones might enhance, rather than inhibit, the innate immune functions, particularly in the early stages of trauma.
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Affiliation(s)
- Ce Yang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Changjiang Zhilu, Daping, Chongqing, China
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Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. ACTA ACUST UNITED AC 2009; 66:1672-6. [PMID: 19509630 DOI: 10.1097/ta.0b013e318185e20e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Empyema is a rare, but morbid complication of diaphragmatic injury. The purpose of this study was to use the National Trauma Databank of the American College of Surgeons to determine (1) the incidence of empyema after diaphragmatic injury, (2) risk factors for development of empyema after these injuries, and (3) the effect of empyema on mortality, hospital, and intensive care unit (ICU) length of stay (LOS) after diaphragm injury. METHODS The National Trauma Databank (v. 5.0) was used to identify adult patients sustaining diaphragmatic injury and surviving for greater than 48 hours. Demographics, injury characteristics, associated abdominal injuries, thoracic procedures, and outcomes data were abstracted for comparison of patients who did and did not develop empyema after these injuries. Stepwise logistic regression analysis was used to identify independent risk factors for the development of empyema. Subsequent adjusted analysis was used to determine the effect of empyema on outcomes (hospital LOS, ICU LOS, mortality). RESULTS Among 4,153 patients with diaphragmatic injury who survived more than 48 hours from admission, 57 (1.4%) developed empyema. Demographics did not differ significantly between the two groups. Empyema was associated with longer adjusted mean hospital (35.9 vs. 16.1, p < 0.001) and ICU (18.1 vs. 8.5, p < 0.001) LOS, but was not associated with increased mortality. Patients with empyema more commonly had associated hollow viscus (63.2% vs. 35.6%, p < 0.001), gastric (40.4% vs. 18.8%, p < 0.001), and splenic injuries (49.1% vs. 33.3%, p = 0.01). After multivariable analysis, two independent risk factors for the development of empyema after diaphragmatic injury were identified: gastric injury (adjusted odds ratio = 2.90; 95% confidence interval: 1.69-5.00; p < 0.001) and Injury Severity Score > or = 20 (adjusted odds ratio = 2.99; 95% confidence interval: 1.61-5.59; p = 0.001). Concomitant colonic injury did not significantly increase the risk of empyema in the study population. CONCLUSIONS Empyema is an uncommon sequela of diaphragm injury that contributes to the need for prolonged hospital and ICU LOSs. Associated gastric trauma and Injury Severity Score > or = 20 were independently associated with empyema development after diaphragmatic injury.
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De Rezende Neto JB, Guimarães TN, Madureira JL, Drumond DAF, Leal JC, Rocha A, Oliveira RG, Rizoli SB. Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile. Injury 2009; 40:506-10. [PMID: 19342047 DOI: 10.1016/j.injury.2008.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 11/11/2008] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent. PATIENTS AND METHODS We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury. RESULTS Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis. CONCLUSION Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.
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Affiliation(s)
- João Baptista De Rezende Neto
- Department of Surgery Universidade Federal de Minas Gerais and Hospital Universitario Risoleta Tolentino Neves, Brazil
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