Effectiveness after Designation of a Trauma Center: Experience with Operating a Trauma Team at a Private Hospital

PURPOSE@#The present study aimed to evaluate the influence of how the trauma care system applied on the management of trauma patient within the region.@*METHODS@#We divided the patients in a pre-trauma system group and a post-trauma system group according to the time when we began to apply the trauma care system in the Halla Hospital after designation of a trauma center. We compared annual general characteristics, injury severity score, the average numbers of the major trauma patients, clinical outcomes of the emergency department, and mortality rates between the two groups.@*RESULTS@#No significant differences were found in the annual patients' average age (54.1±20.0 vs. 52.8±18.2, p=0.201), transportation pathways (p=0.462), injury mechanism (p=0.486), injury severity score (22.93 vs. 23.96, p=0.877), emergency room (ER) stay in minutes (199.17 vs. 194.29, p=0.935), time to operation or procedure in minutes (154.07 vs. 142.1, p=0.767), time interval to intensive care unit (ICU) in minutes (219.54 vs. 237.13, p=0.662). The W score and Z score indicated better outcomes in post-trauma system group than in pre-trauma system group (W scores, 2.186 vs. 2.027; Z scores, 2.189 vs. 1.928). However, when analyzing survival rates for each department, in the neurosurgery department, in comparison with W score and Z score, both W score were positive and Z core was higher than +1.96. (pre-trauma group: 3.426, 2.335 vs. post-trauma group: 4.17, 1.967). In other than the neurosurgery department, W score was positive after selection, but Z score was less than +1.96, which is not a meaningful outcome of treatment (pre-trauma group: −0.358, −0.271 vs. post-trauma group: 1.071, 0.958).@*CONCLUSIONS@#There were significant increases in patient numbers and improvement in survival rate after the introduction of the trauma system. However, there were no remarkable change in ER stay, time to ICU admission, time interval to emergent procedure or operation, and survival rates except neurosurgery. To achieve meaningful survival rates and the result of the rise of the trauma index, we will need to secure sufficient manpower, including specialists in various surgical area as well as rapid establishment of the trauma center.

Bilateral Chylothorax Due to Blunt Spine Hyperextension Injury: A Case Report

Bilateral chylothorax due to blunt trauma is extremely rare. We report a 74-year-old patient that developed delayed bilateral chylothorax after falling off a ladder. The patient had a simple 12th rib fracture and T12 lamina fracture. All other findings seemed normal. He was sent home and on the 5th day visited our emergency center at Halla Hospital with symptoms of dyspnea and lower back pain. Computer tomography of his chest presented massive fluid collection in his right pleural cavity and moderate amounts in his left pleural cavity with 12th rib fracture and T11-12 intervertebral space widening with bilateral facet fractures. Chest tubes were placed bilaterally and chylothorax through both chest tubes was discovered. Conservative treatment for 2 weeks failed, and thus, thoracic duct ligation was done by video assisted thoracoscopic surgery. Thoracic duct embolization was not an option. Postoperatively, the patient is now doing well and happy with the results. Early surgical treatment must be considered in the old patient, whom large amounts of chylothorax are present.

Large Focal Extrapleural Hematoma of Chest Wall: A Case Report

Although hemothorax and pneumothorax are common complications seen in rib fractures, focal extrapleural hematoma is quite rare. We report a 63-year-old female patient that developed large focal extrapleural hematoma after falling off a second floor veranda. The patient had sustained 3, 4, 5th costal cartilage rib fractures and a sternum fracture. She had developed suspected empyema with loculations with small amount of hemothorax. She underwent a planned early decortication/adhesiolysis by video assisted thoracoscopic surgery at the 12th post-trauma day due to failed drainage. Unexpectedly, she had no adhesions or any significant retained hematoma mimicking a mass, but was found with the focal extrapleural chest wall hematoma. She was discharged on postoperative 46th day for other reasons and is doing fine today.

Rib Fixation for a Patient with Severely Displaced and Overlapped Costal Cartilage Fractures

Rib fixations for flail chest or displaced rib fractures are not a new technique. However, reports on rib fixations involving costal cartilage fractures are very few and surprisingly there are no reports of internal fixations involving only the costal cartilage in the English literature. The diagnosis is difficult and the necessity of the procedure may be quite controversial. Placing plates in screws into the costal cartilage alone may seem unstable and easily dislodged or stripped through the cartilage. We report a 31-year-old male scuba diver instructor who underwent rib fixations over his 7th and 8th costal cartilage ribs for severe pain. The procedure was done with conventional plates and screws. He had the plates and screws removed 2 months later due to lingering pain, but with them removed he is now quite happy with the results without pain. The procedure for fixation of painful overlapped costal cartilage is quite simple and can be done with the usual conventional methods, fixating plate and screws directly over the cartilage alone without fixation over the bony rib.

Esophageal Rupture Due to Diving in Shallow Waters

Delayed esophageal rupture due to blunt injury is not new. However, rupture due to suspected barotrauma is very rare. We describe a case of esophageal rupture in a male 24-year-old patient after diving in shallow waters. The patient was quadriplegic and could not experience the typical chest pain related to rupture and resulting mediastinitis. The rupture was discovered 4 days after emergency decompressive laminectomy and fusion for his cervical spine. The rupture was evidently caused by barotrauma and was discovered four days after admission. He underwent primary closure and pericardial flap as a life-saving procedure.

Nonossifying Fibroma of the Rib Resected by Video-Assisted Thoracoscopic Surgery with Preservation of Periosteum

Nonossifying fibromas are not uncommon, but those described in the rib are unique. We report the case of a 15-year-old patient with symptoms of chest wall pain for 5 days who underwent a video-assisted thoracoscopic rib resection for a 2.5-cm rib mass. Unexpectedly, pathological results revealed a nonossifying fibroma of the rib. The results showed excellent cosmesis and new bone formation because of the preservation of the overlying periosteum.

Silastic Molding Method for Pectus Excavatum Correction Using a Polyvinyl Alcohol (Ivalon) Sponge

Pectus excavatum is rare, but it is the most common type of sternal congenital disorder. There are many surgical methods to correct pectus excavatum such as the Ravitch method, Wada method, Silastic mold method, and the Nuss operation. We report a case of minimal invasive surgery for pectus excavatum using a polyvinyl alcohol sponge.

Rhabdomyolysis in a chronic kidney disease patient after lung surgery / 대한마취과학회지

No abstract available.

Postinfarct Ventricular Septal Defect after Coronary Covered Stent Implantation

We report a case of a postinfarction ventricular septal defect caused by an acute recurrent occlusion after the implantation of a covered stent, which was performed as a rescue procedure for the ruptured left anterior descending artery during a percutaneous coronary intervention. Although the emergent implantation of a covered stent for the ruptured coronary arteries such as the left main coronary artery or the origins of the left anterior descending artery can be performed during a percutaneous coronary intervention, and a coronary bypass surgery should be considered in order to decrease the risk of complete occlusion, thus providing a superior long term patency.

A case of a pericardial window procedure performed by needlescopic surgery in a hemodialysis patient / 대한내과학회지

With the advent of 2- and 3-mm endoscopic instruments, a thoracoscopic pericardiectomy can be performed with relative ease and with almost no postoperative scar. We report a case of a 40-year-old woman with end-stage renal disease who had a large volume of pericardial effusion that did not abate after repeated dialysis. A pericardial window was performed by needlescopy for diagnostic and therapeutic reasons, and her postoperative scar was minimal. Her postoperative course was uneventful, and she has had no complications or recurrence of pericardial or pleural effusion.

Hemothorax in an Uncontrolled Anticoagulated Patient: Fight or Flight?: A Case Report / 대한구급학회지

Hemothorax in a patient on anticoagulant therapy for atrial fibrillation after blunt trauma is not an uncommon event. However, massive hemothorax in such a patient with an extremely uncontrolled and high international normalized ratio (INR) may pose a serious dilemma. We report a case of a patient under anticoagulant therapy for atrial fibrillation who underwent an emergent thoracotomy for massive hemothorax with an INR of 9.57.

Clinical Analysis of Repeated Heart Valve Replacement / 대한흉부외과학회지

BACKGROUND: There are two choices for heart valve replacement-the use of a tissue valve and the use of a mechanical valve. Using a tissue valve, additional surgery will be problematic due to valve degeneration. If the risk of additional surgery could be reduced, the tissue valve could be more widely used. Therefore, we analyzed the risk factors and mortality of patients undergoing repeated heart valve replacement and primary replacement. MATERIAL AND METHOD: We analyzed 25 consecutive patients who underwent repeated heart valve replacement and 158 patients who underwent primary heart valve replacement among 239 patients that underwent heart vale replacement in our hospital from January 1995 to December 2004. RESULT: There were no differences in age, sex, and preoperative ejection fraction between the repeated valve replacement group of patients and the primary valve replacement group of patients. In the repeated valve replacement group, the previously used artificial valves were 3 mechanical valves and 23 tissue valves. One of these cases had simultaneous replacement of the tricuspid and aortic valve with tissue valves. The mean duration after a previous operation was 92 months for the use of a mechanical valve and 160 months for the use of a tissue valve. The mean cardiopulmonary bypass time and aortic cross clamp time were 152 minutes and 108 minutes, respectively, for the repeated valve replacement group of patients and 130 minutes and 89 minutes, respectively, for the primary valve replacement group of patients. These results were statistically significant. The use of an intra aortic balloon pump (IABP) was required for 2 cases (8%) in the repeated valve replacement group of patients and 6 cases (3.8%) in the primary valve replacement group of patients. An operative death occurred in one case (4%) in the repeated valve replacement group of patients and occurred in nine cases (5.1%) in the primary valve replacement group of patients. Among postoperative complications, the need for mechanical ventilation over 48 hours was different between the two groups. The mean follow up period after surgery was 6.5+/-3.2 years. The 5-year survival of patients in the repeated valve replacement group was 74% and the 5-year survival of patients in the primary valve replacement group was 95%. CONCLUSION: The risk was slightly increased, but there was little difference in mortality between the repeated and primary heart valve replacement group of patients. Therefore, it is necessary to reconsider the issue of avoiding the use of a tissue valve due to the risk of additional surgery, and it is encouraged to use the tissue valve selectively, which has several advantages over the use of a mechanical valve. In the case of a repeated replacement, however, the mortality rate was high for a patient whose preoperative status was not poor. A proper as sessment of cardiac function and patient status is required after the primary valve replacement. Subsequently, a secondary replacement could then be considered.

Giant Venous Aneurysm after Brachiocephalic Arteriovenous Shunt for Hemodyalisis Access: A case report / 대한흉부외과학회지

We report a case of a 46-year-old man with end-stage renal failure who developed a giant aneurysm after a brachiocephalic arteriovenous shunt. The patient had complaints of pulsating pain and swelling of his left upper extremity. The patient had abandoned use of the arteriovenous shunt and had a second arteriovenous shunt procedure over his right extremity. The giant venous aneurysm was removed just distal to his anastomosis. The patient's postoperative course was uneventful.

A Case Report of Thymic Carcinoid Tumor Associated with Cushing's Syndrome: Possible Corticotropin-Releasing Hormone Secreting Tumor / 대한흉부외과학회지

Thymic carcinoid tumor associated with Cushing's syndrome is a rare disease with a poor prognosis. Thymic carcinoid with Cushing's syndrome caused by CRH (corticotropin-releasing hormone) production is even rarer. We report a 58-year-old woman with a huge anterior mediastinal mass. Five months after thymectomy the patient was readmitted with symptoms of generalized edema and dyspnea. Recurrence and metastases were discovered and Cushing's syndrome diagnosed.

Analysis of Postoperative Coronary Angiography in Symptomatic Patients / 대한흉부외과학회지

BACKGROUND: We analyzed post-operative angiography performed in symptomatic patients to evaluate the patency rates and the roles of grafts. MATERIAL AND METHOD: We reviewed 52 (15%) coronary angiograms performed for recurrent angina after prior coronary artery bypass surgery from January 1995 to June 2005. A total of 345 patients underwent coronary artery bypass surgery during this period. There were 41 men and 11 women and the mean age was 64.07+/-15.58 years. The median period from operation to re-angiogram was 68.5 months (range, 1 to 126 months). The numbers of grafts and peripheral anastomoses were 42 and 43 for internal thoracic artery (ITA), 14 and 20 for radial artery (RA), and 49 and 89 for saphenous vein. The mean number of anastomosis was 2.9 per patient. RESULT: The patency rates of ITA, RA and saphenous vein graft (SVG) were 37/43 (86%), 17/20 (85%) and 34/89 (38.2%). The patency rate of arterial grafts was significantly higher than that of SVG (p<0.001) and the patency rate of the RA was comparable to that of ITA (p=0.912). The patency rate of sequential SVGs was higher than that of single SVG (40.3% vs 31.8%, p=0.478) and the patency rate of proximal segments in sequential anastomosis was higher than that in single anastomsis (55.6% vs 31.8%, p=0.097), but statistically not significant. CONCLUSION: Arterial grafts have markedly superior patency rates than SVGs, so consideration should be given to the vigorous use of arterial grafts. The patency rate of the RA was comparable to that of ITA.

Clinical Analysis of Spontaneous Pneumomediastinum / 대한흉부외과학회지

BACKGROUND: Spontaneous pneumomediastinum (SPM) is a relatively rare and benign condition that generally occurs in young adults without any precipitating factor or disease. The purpose of this study was to assess whether more uncomforting diagnostic procedures are necessary and to establish standards in the diagnosis and treatment of spontaneous pneumomediastinum. MATERIAL AND METHOD: A retrospective study was done on 18 patients from the hospitals of Hanyang University Seoul Hospital and Hanyang University Guri Hospital between February, 1997 and June, 2004. All patients had presence of mediastinal air without a pneumothorax and no evidence of trauma or barotrauma. RESULT: Among the 18 patients, the majority were male patients with only two female patients. Their mean age was 20.95 years old with standard deviation of 14.3 years. The most common complaints were chest pain, dyspnea, and coughing. Evaluation included simple chest roentgenogram in all patients, 10 patients had a chest tomographic scan, 10 patients had an esophagoscopic exam, 6 patients had a bronchofiberoscopic exam, and 3 patients had an esophagogram done. The mean hospital stay was 10.9 days. All patients were treated conservatively and in a follow-up of 1~8 years only one recurrence was found. CONCLUSION: SPM is caused by alveolar rupture in the pulmonary interstitium leading to dissection of air towards the hilum and mediastinum. Although SPM is a self-limiting condition, evaluation should include chest roentgenogram and chest tomographic scans to rule out any other secondary condition. More aggressive evaluation seems unnecessary.

Tricuspid Replacement through Right Thoracotomy in Reoperation: A case report / 대한흉부외과학회지

In an extremely enlarged right heart, the repeated midline sternotomy was considered to involve the risk of massive hemorrhage. A right thoracotomy provides a convenient and safe way to approach the tricuspid valve in patient who have had previous heart surgery through a midline sternotomy.

Venous Backflow in a Patent Polytetrafluoroethylene Arteriovenous Graft: A case report / 대한흉부외과학회지

We report a case of a 48-year-old woman with end-stage renal failure who had a Polytetrafluoroethylene graft for hemodialysis and who had developed complications of venous outflow stenosis and venous backflow. Although venous backflow is an harbinger of graft failure, it is not enough reason to abandon the graft immediately. The patient was able to utilize her graft for 6 further months.

Expressions of Laminin-1 in Lung Alveolar Septa after CS gas Exposure in Rats / 결핵및호흡기질환

BACKGROUND: Laminin-1 is known to have regular functions in the development and course of differentiation of the lungs. The morphogenesis and distribution of laminin-1 still remains as a mystery and its distribution and changes in the molecular structure of laminin-1 in the pathogenesis of the lung still is a subject of great controversy. In this study, experiments were done to delineate the distribution and changes in the amount of laminin-1 after inducing inflammation of the lungs by exposing experimental animals to CS gas and especially, to find compositions of laminin-1 within type II pneumocytes. MATERIALS AND METHODS: The experimental subjects of study were newborn rats and the extracted tissue from the experimental rats were viewed under light microscope and electron microscope after the sections were treated with immunohistochemical methods and immunogold reaction methods using bounded gold particles. RESULTS: 1) Lymphocytes and mononuclear phagocytes invaded the alveolar septa in the 2 day group rats after CS gas exposure and intense interstitial inflammation was seen in the 3 day group. 2) Laminin immunoreactions decreased to a moderate degree in the 2 and 3 day group rats after CS gas exposure and strong laminin immunoreactions were seen again in the 5 and 7 day group rats. 3) Gold particles in basal lamina of the lung blood-air barrier decreased and in the type I pneumocytes decreased in the 2 and 3 day group rats after CS gas exposure. 4) Gold particles were seen only on the surface of the cell membranes of type II pneumocytes of the 1 and 2 day group rats after CS gas exposure. 5) Few gold particles around the lamellar bodies and cytoplasm of type II pneumocytes in the control rat group and at 12 hours after CS gas exposure. Gold particles are seen only on the surface of type II pneumocytes of the 1 and 2 day group rats after CS gas exposure and are evenly distributed in small amounts in the cells of the 3 day group after CS gas exposure. CONCLUSION: CS gas exposure in the rats caused inflammation of lung alveolar septa and also induced a decrease in laminin-1 in basal lamina and loss of laminin-1 in the cytoplasm of type II pneumonocytes. As the inflammatory cells disappeared, an increase in the distribution of laminin-1 occurred. This reflects tissue regeneration functions of laminin-1 in the pneumocytes of rats and the distribution of laminin-1 in type II pneumocytes can be seen through the electron microscope using immunogold methods.

Traumatic Complete Renal Avulsion Herniating into the Left Pleural Cavity: A case report / 대한흉부외과학회지

Herniation of the kidney through a traumatic diaphragmatic rupture in itself is rare. However, complete avulsion of the renal pedicle implies not only a more rare event, but also a surgical emergency. We report a case of a patient with complete avulsion of renal vessels and ureter of an intrathoracic kidney herniated through a diaphragmatic rupture caused by blunt trauma. Prompt diagnosis with a computer tomographic scan and immediate surgery saved the patient's life.