ABSTRACT
Background: Penetrating wounds to the heart and great vessels are fatal unless treated surgically on an emergency basis. The survival after surgery depends on many factors
Aim: The aim of this study is to analyze the clinical spectrum of 58 cases of penetrating wounds to the heart and grea. vessels operated upon in Mansoura Emergency Hospital in the last 8 years, and to determine the factors affecting the results of surgery
Patients and methods: Fifty eight patients with penetrating wounds to the heart and great vessels presented to the emergency room [ER] in Mansoura Emergency Hospital [MEH] from January 1996 to December 2003. The file data of them were analyzed retrospectively. The age, gender, site and mechanism of injury was reviewed. The patients were classified on arrival to the Emergency Room [ER] into 4 categories according to their clinical and functional status. These were [1] Stable patients: 17 patients [29.3%] [2] Shocked and unstablez18 patients [31%]. [3] Agonal: 13 patients [22.4%]. [4] Fatal: 10 patients [17.2%]
Results: There were 56 males [96.55%] and 2 females [3.45%]. The mean age was 27.64 +/- 8.33 years [range 7-47 years]. The causes of injury were stabs in 50 patients [86.2%], gunshots in 7 [12.06 %] and iatrogenic in one patient [1,72%]. There were 50 injuries to the heart [86.2%] and 6 to the aorta [10.34], and 2 to the main pulmonary artery [3.44%]. 12 patients had associated penetrating injuries [20.6%]. All the patients were operated upon, 13 [22.4%] had ER thoracotomy and 45 [77.6%] patients had formal theater thoracotomy. Approach was through left anterior thoracotomy in 47 [81%] , median sternotomy in 10 [17.24%] and left posterior thoracotomy in 1 patient [1.7%]. The site of injury was right ventricle in 26 cases [44.8%], left ventricle in 22 [37.9%] , aorta in 4 [6.85%], right atrium in 4 [6.85%], pulmonary artery 4 [6.85%], left atrium 2 [3.45%], and multiple injuries in 6 [10.43%]. Associated penetrating injuries were found in 16 patients [27.5%]. There were 5 injuries to the lungs, 4 had additional penetrating iniuries to the chest wall structures, 5 to the diaphragm, and 2 to the liver. There were 14 deaths in this series [24.1%] , 8 of them in the fatal group that reached the ER in arrest and managed by ER thoracotomy, only 2 out of 10 could be salvaged [20%] and 80% mortality was faced in this group of patients. The Agonal [tamponading] group suffered 2 intraoperative mortalities due to extensive tear in one victim and pump failure in the other. The other 4 cases were in the shocked group, one due to massive liver tear, one due to circulatory collapse, one had intractable postoperative arrhythmia, and one died of septicemia end DIC. There were 11 complications occurring in 8 patients out of the surviving 44 patients [18.2%]. Wound infection in 3 cases including one case of median Sternotomy, 2 cases of pneumonia, 2 postoperative empyema, 2 cases of residual cerebral deficit due to arrest just before reaching ER, one case of myocardial infarction, due to injury to the distal left anterior descending coronary artery, and one case of arrhythmia following repair of a relatively long right ventricular tear. The mean ICU stay was 2.67 +/- 0.74 days, and the mean hospitalization time was 10.65 +/- 3.73 days. Predictors of mortality of statistical significance were found to be: gunshot type, arrival in near arrest, and multiple associated injuries
Conclusions: penetrating injuries to the heart and great vessels increased significantly in our society due to increased attitude toward violence in young adults. Stabs being the most common type. Rapid ambulance transportation, high index of suspicion of cardiac tamponade, first aid for shocked victims, are need to improve the results of this type of emergency. Utmost care must be given to patients with gunshot wounds, arriving in near arrest and with multiple associated injurie
ABSTRACT
Background: Bronchial carcinoid tumors are relatively rare tumors. These tumors were wrongly considered as bronchial adenomas till 3 decades ago. Now these tumors are classified as neuroendocrine bronchopulmonary tumors of lower grade of malignancy that arise from Kulchitsky cells
Aim: to study the spectrum of pulmonary carcinoids presented from our locality, demonstrating its clinicopathological profile. Also to analyze our results of surgery for these tumors and compare it with those of other centers to define the influence of the site of the tumor, carcinoid histological category , and lymph node involvement on the outcome of surgery
Patients and methods: Forty three patients with pulmonary carcinoid tumors were surgically treated at the Department of Cardiothoracie Surgery, Mansoura University Hospitals, through a period of 10 years ending December 2003. The files of all the patients were retrospectively revised for the demographic profile, clinical data, and findings of both rigid and fiberoptic bronchoscopy done to the patients. Also data extracted from CT scans and virtual CT bronchoscopy were collected and tabulated. All the patients had pulmonary resection varying from pneumonectomy till segmentectomy , according to the location and extent of the tumors. All the resectd pulmonary specimens, along with its hilar and mediastial lymph nodes were examined histopathologically, and reviewed according to the current WHO/IASLC criteria for neuroendocrine tumors. Patients were followed up from 1 to 10 years for recurrence and long term survival in relation to both typical and atypical carcinoid categories, LN affection , central and peripheral location. Results were recorded and tabulated for deduction of statistical significance
Results: The patients had a mean age of 39.35 +/- 8.55 years [range 21-64 years], 27 were females [62.79%] and 16 were males [37.3%]. Thirty five patients were symptomatic [79.1%]. Haemoptysis was the most common presenting symptom, occurring in 22 patients [51.1%]. Only 9 patients were asymptomatic [20.9 %]. Data from CT scan and bronchoscopy revealed that 29 patients [67.4%] had central tumors while 14 cases had peripheral ones. Preoperative tissue diagnosis was obtained in 22 patients [51%]. The 43 patients has 43 Operative; 21 had lobectomies, 19 had bilobectomies, one formal and one completion pneumonectomy and one segmentectomy. Typical carcinoid type was found in 35 patients [[81.3%] and eight cases had atypical carcinoid [18.7%]. Of the 35 patients with typical carcinoid. 5 had lymph node involvement [14.2%], while 3 out of 8 cases of atypical carcinoid [37.5%] showed lymph node involvement. We had one hospital mortality [2.3%] due to pulmonary embolism in an obese male aged 61 years, W. had 10 postoperative complications in 6 patients [13.9%] . We found no statistically significant correlation between the incidence of morbidity and hospital mortality and the carcinoid tissue type , place of the tumor or LN affection. Follow up: Out of the typical carcinoid group [34 surviving patients]. 29 Patients who had no LN involvement had 5 year disease free Survival of 96.55%. Out of the 5 cases with LN involvement had 5 year disease free survival 80%. Out of the atypical carcinoid group [8 surviving cases] , 5 cases who had no LN involvement had 5 year disease free survival 60%. Three cases with LN involvement, got 5 year disease free survival of 33% at the end of 5 years of follow up. By comparing results of different groups, significant predictors of 5 year disease free survival are typical carcinoid histology, absent mediastial LN involvement , and peripheral type of carcinoid
Conclusions: Carcinoid tumor is not uncommon bronchial tumor that affects females more than males. Long term survival is favorable in typical carcinoid with no LN affection, prognosis is better in peripheral type. atypical carcinoids have worse long term survival rates and recurrence Patterns, a wide surgical resection with LN clearance is essential for successful long term disease free Survival