Blunt chest trauma

A retrospective study was conducted at the cardiothoracic surgical unit of the University College Hospital, Ibadan on all consecutive, blunt chest injury patients treated between May 1975 and April 1999. The period of study was divided into 2 periods: May 1975-April 1987, May 1987-April 1999. The aim was to determine the pattern of injury, the management and complications of the injury among the treated. Blunt chest trauma patients were 69% (1331 patients) of all chest injury patients (1928 patients) treated. Mean age for the 2 periods was 38.3 +/- 15 years and 56.4 +/- 6.2 years, the male:female ratio was 4:1 and 2:1 respectively. The incidence of blunt chest trauma tripled in the second period. Blunt chest trauma was classified as involving bony chest wall or without the involvement of bony chest wall. Majority of the blunt chest injuries were minor chest wall injuries (68%, 905 patients), 7.6% (101 patients) had major but stable chest wall injuries, 10.8% (144 patients) had flail chest injuries. Thoracic injuries without fractures of bony chest wall occurred in 181 patients (13.6%). Seven hundred and eighty-seven patients (59.1%) had associated extra-thoracic injuries, in 426 patients (54.1%) two or more extra-thoracic systems were involved. While orthopaedic injury was the most frequent extra-thoracic injury (69.5%) associated with blunt chest trauma, craniospinal injury (31.9%) was more common injury among the patients with severe or life threatening chest trauma. The most common extra-thoracic operation was laparotomy (221 patients). Nine hundred and seventy patients (72.9%) had either closed thoracostomy drainage or clinical observation, 361 patients (27.1%) had major thoracic surgical intervention (emergent in 134 patients, late in 227 patients). Most of the severe lung contusion that needed ventilatory care (85 patients) featured among patients with bony chest wall injury, 15 were without chest wall injury. Majority of patients 63.2% (835 patients) had no significant complications, 486 patients (30.8%) of 1321 survivors had 741 complications. The commonest complications were atelectasis (201 patients) and pleural space complications (263 patients). Overall mortality was 36.2% (154 patients) among 426 patients. We conclude that majority of blunt chest trauma can be managed by simple procedures with minimal complications. Severe soft tissue chest injuries can occur without bony chest wall fractures.

Trans-hiatal oesophagectomy as palliative treatment for carcinoma of the oesophagus

OBJECTIVE

To determine the role of palliation with trans-hiatal oesophagectomy in Nigerian patients with carcinoma of the oesophagus.

DESIGN

Prospective case series. The first series was from February 1986 to September 1987 (Series A) while the second series was from March 1989 to November 1996 (Series B).

SETTING

Cardiothoracic Surgery Unit (CTSU) of the University College Hospital, Ibadan, Nigeria.

SUBJECTS

First series consisted of 10 consecutive operable patients with carcinoma of oesophagus seen over the period of study. The second series consisted of 21 consecutive patients with same disease.

INTERVENTION

All patients had transhiatal oeosphagectomy by a two team approach and immediate placement of the freed stomach in the posterior mediastinum and cervical oesophagogastrostomy.

RESULTS

Patients in both series had a comparable age range of 43 - 80 years for series A and 40 - 82 years for Series B. The duration of symptoms were 2 - 6 months and 2 - 12 months respectively, for series A and B. In series A, nine patients had carcinoma of the middle-third (M1/3) of the thoracic oesophagus and one patient had carcinoma of lower-third (L1/3) of the thoracic oesophagus. In series B, 18 patients had M1/3 and three patients had L1/3 lesions. Average blood loss in series A was 1,067 mls, corresponding value for series B was 852 mls. Postoperatively, all cases were classified as stage III or stage IV disease. There were 18 complications in eight patients in series A and 22 complications in 10 patients in series B. The commonest complications in series A were pleural enteries in six patients, haemorrhage four patients (three intraoperative, one post-operative) and respiratory failure (two patients). The commonest in series B were pleural enteries in nine patients, anastomotic leaks and stenosis in four patients and respiratory failure in three patients. Hospital mortality was 50% in Series A and 14.3% in series B. The causes of death were haemorrhage and respiratory failure in series A, respiratory failure in series B. Survival period in series A of the five patients discharged was for a median of 84 months, for series B, four patients were alive at 18 months post-operative, one patient attended follow-up clinic 24 months after surgery. No other adjunctive therapy was offered to the patients.

CONCLUSION

Trans-hiatal oesophagectomy is a procedure suitable for patients with carcinoma of the oesophagus and affords palliation at an "acceptable price" among carefully selected patients with advanced carcinoma of the oesophagus.

Trans-oral irrigation for the management of cervical esophagogastric anastomotic leak

Over a period of 8 years, 15 of the 65 patients who had transhiatal esophagectomy (THE) for esophageal diseases and cervical esophagogastrostomy had cervical oesophagogastric anastomotic leak. Seven of the 18 patients (38.9%) with corrosive esophageal strictures (CES) due to acid burns had anastomotic leaks while 2 out of 6 patients (33.3%) and 6 out of 41 patients (14.6%) were the incidences of anastomotic leaks among alkali burnt and carcinoma of the esophagus. Anastomotic leaks were more commonly associated with surgery for CES. They were managed by trans-oral irrigation with water after ingestion of either soft/solid diet or high protein, high carbohydrate fluid diet along with adequate jejunostomy feeding. The age of the patients ranged between 5 to 65 years (mean 38.8 +/- 15.7 year). Anastomotic leaks were diagnosed between 3rd to 10th postoperative day (mean 7.1 +/- 2.6 day). The period of transoral irrigation before closure of leakage ranged from 2 to 14 days (mean 6.1 +/- 2.9). In 12 patients (80%) anastomotic leakage closed within 5 days, (mean 3.9 +/- 1.0). Two weeks after closure, all the patients had bouginage and every two weeks for another 3 dilation. Four of the 15 patients needed repeated two monthly dilation for 8 to 12 months. There were no other complications nor mortality in this study. There was psychological acceptance of this minimally invasive procedure.

Penetrating chest injuries in civilian practice

The purpose of this retrospective study is to show the pattern of penetrating chest injury, methods of management and the outcome. Were viewed all consecutive penetrating chest injured patients admitted to the Cardiothoracic Surgical Unit of the University College Hospital, Ibadan between May 1975 and April 1999. We found that 597 patients had penetrating chest injuries. This was 31% of all chest injuries treated. To analyse pattern of injuries, period of study was divided into 2 periods of 12 years each, May 1975 to April 1987 (Group A) and May 1987 to April 1999 (Group B). Mean ages of the patients in group A and B were, respectively, 27 +/- 12.5years and 48 +/- 10.2 years; male:female ratio for the 2 groups were 20:1 and 17:1, respectively. The main mechanisms of injury were gunshot wounds (GSW) in 364 patients (61%) and stab wounds (SW) in 214 patients (35.8%). The ratio of GSW to SW was reversed for the 2 periods, 1:3 for group A and 7:1 for group B. Nine patients died during resuscitation. Four hundred and eleven patients of 588 patients (69.9%) were managed conservatively. Sixty-five (11.1%) by clinical observation and 346 (58.8%) by closed thoracostomy drainage. Mortality among the conservatively managed was 2.2%, morbidity was 18.2% (75 out of 411 patients). Ninety patients had early major surgery, 75 had late major surgical management of complication of conservative management. The operative mortality was 22% (in 39 patients). The determinant of mortality were haemorrhage, respiratory insufficiency and sepsis. We conclude that penetrating injury is a third of chest injuries we see. It is commoner in men and currently involves the older age group and it is most frequently inflicted by gunshot. Majority may be managed conservatively with low incidence of complications. Prompt major surgery limits mortality among the salvageable.

Anterior mediastinotomy--a diagnostic tool

This is a review of our experience with anterior mediastinotomy (AM) in the diagnosis and evaluation of diseases of the mediastinum and lung. Thirty consecutive patients who had AM between 1984 and 1999 were retrospectively studied. The mean age of patients was 28 +/- 6.5 years. There were 22 males to 8 females. Sixteen patients had superior vena cava (SVC) obstruction (12 patients with lung cancer, 4 with primary mediastinal tumours), 4 patients had radiological evidence of mediastinal contiguity of upper lobe tumours and 10 patients had primary mediastinal tumours. AM was 1st procedure in 10 patients and 2nd procedure in 20 patients after failed or inconclusive result from FNAB, scalene node/cervical lymph node biopsy or bronchoscopy. Eighteen right-sided and 12 left-sided AMs were performed. Satisfactory histological diagnoses were achieved in all patients. Complications were easily controlled bleeding (4 patients) and life-threatening haemorrhage in 2 patients. Three patients had delayed wound healing and 4 had inadvertent pleural entries. There was no mortality temporarily related to the procedure. We conclude that AM is valuable as a surgical technique for obtaining tissue for histological purposes in diseases of the mediastinum and the lung when tissue specimens from less invasive procedures are unsatisfactory.

Closed chest drainage without an underwater seal

Six hundred and eighty-five patients requiring pleural drainage were referred to and managed by the Cardiothoracic Unit of the University College Hospital, Ibadan between June 1985 and September 1992. Two hundred patients, in which Aldon's urobag (e.g. Simpla S4 type) was used for pleural drainage were studied. The indications for pleural drainage were pyothorax or pyopneumothorax (106 patients), malignant pleural effusion (53 patients), tuberculous effusions (23 patients) and chest trauma (18 patients). In seven of these patients, the Aldon's urobag was used for out-patient care pleural drainage. Some of the reasons for discontinuing its use were major tracheobronchial injuries (2 patients), clotted haemothorax (5 patients), chronic empyema thoracis (10 patients) and loculated malignant pleural effusions. The few easily surmountable complications encountered were obstruction of the tube by blood clot and fibrinous coagulate, stoma necrosis and periosteal reaction. The advantages observed from the use of Aldon's urobag for pleural drainage were reduction in cost of pleural drainage, availability of this drainage system and its use for out-patient care when indicated.