War injuries to the chest.

AIM: Presentation of our experiences in the treatment of war injuries to the chest at the Split University Hospital, Croatia, during the 1991-1995 war in Croatia and Bosnia-Hercegovina. METHODS: Retrospective analysis of clinical and surgical data on 439 (16.3%) patients with war injuries to the chest among 2693 treated battle casualties in general. The medical data from evacuation unit, transportation, emergency department and follow-up were observed and processed by basic statistical analysis. RESULTS: There were more explosive wounds than gunshot and puncture wounds (ratio 251/158/30). Penetrating injuries were found in 348 (79%) patients and nonpenetrating in 91 (21%) patients. There were 401 (91%) men and 38 (9%) women. Thoracotomy was performed in 98 (22.3%) patients, whereas conservative surgical methods (wound treatment, chest-tube drainage, appropriate fluid therapy, antimicrobial and atelectasis prophylaxis) were used in 341 (77.7%) patients. Mean time elapsed between injury and definitive surgical repair was seven hours (range, 1 to 48 hours). Recovery on discharge was recorded in 411 (93.6%) patients, 19 (4.3%) patients were referred to other institution for further treatment, and 9 (2%) severely wounded persons died. CONCLUSIONS: The treatment of respiratory insufficiency and haemorrhage shock, and prevention of infection are the basis of management of these injuries. Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the chest. Most war wound of the lung can be successfully managed by "conservative" surgical treatment. The recovery of lung function was similar in conservatively and operatively treated patients.

[Video thoracoscopic therapy of recurrent spontaneous pneumothorax]. / Videotorakoskopsko lijecenje recidivnoga spontanog pneumotoraksa.

We report our first experience in surgical treatment of recurrent spontaneous pneumothorax using video-assisted thoracic surgery (VATS). From May 1995 to April 1998, 38 cases of recurrent spontaneous pneumothorax were treated using the VATS approach. All patients were previously treated by other methods (conservative, thoracocentesis, chest-tube drainage). We successfully managed VATS procedure in all our patients (wedge resection 28, bullectomy 1, partial pleurectomy 2, pleural abrasions 36). Complications include persistent air leak (4), prolonged bleeding (1) and supraventricular tachycardia (1). The mean duration of chest drainage was 3.9 days (range 3 to 15 days). All patients received antimicrobial chemoprophylaxis with single-dose of 2 g Ceftriaxone intravenously prior to surgery and average postoperative patient-controlled analgesia with 0.15 mg of buprenorphin. Utilisation resource analysis showed great advantage in favour of VATS procedure compared to retrospectively analysed thoracotomied patients. We conclude that VATS is very useful alternative to conventional thoracotomy in managing cases of recurrent spontaneous pneumothorax.

Our experience with 2693 wounded treated at the Split University Hospital during the 1991-1995 period.

The authors' personal experience of 2693 wounded treated at the Split University Hospital during the 1991-1995 period is described and compared with the results reported from other recent wars worldwide. Explosive wounds were more frequent than gunshot wounds (N=1490; 55.3% vs N=988; 36.7%), and wounds due to other factors were observed in 215 (8.0%) patients. There were 2494 (92.6%) men and 99 (7.4%) women. A total of 1815 (67.4%) patients were operated on in field war hospitals, and 878 (32.6%) at the Split University Hospital. Recovery and discharge were achieved in 1527 (56.7%) and improvement with the treatment or rehabilitation continued at other institutions in 850 (31.6%) patients. In 240 (8.9%) patients, no definite opinion can yet be given. A lethal outcome was recorded in 76 (2.8%) patients. Rapid transportation from the site of wounding to medical teams was found to be of paramount importance for successful treatment. These teams were placed in field war hospitals placed as close as possible (5-15 km) to the frontline.

[Our initial experience with video-assisted thoracoscopic surgery (VATS)]. / Nasa prva iskustva u videotorakoskopskoj kirurgiji (VATS).

Diagnostic and therapeutic potentials and our first two-year experience with video-assisted thoracic surgery (VATS) are reported. From May 1995 to April 1997, at the Department of Surgery, University Hospital Split, VATS approach was planned in 55 cases (recurrent pneumothorax in 23, tension pneumothorax in 1, traumatic effusion in 5, malignant metastatic lung tumor in 1, benignant lung tumor in 11, traumatic effusion in 5, suspected mediastinal lymph nodes in 4, long lasting unconfirmed pleural effusion in 9, foreign body in 1, mediastanal cyst in 1). Of these, 48 procedures (87.2%) were performed using VATS (diagnostic thoracoscopy in 12, wedge resection with or without pleural abrasion in 21, partial pleurectomy in 1, decortications in 3, mediastinal lymph nodes biopsy in 4, lung biopsy in 7). Seven patients (12.7%) underwent conventional posterolateral thoracotomy. Complications included persistent air leak in three patients, prolonged bleeding in one patient and supraventricular tachycardia in one patient. The mean duration of chest tube drainage after the procedure was 3.7 days (range 2 to 19 days), and mean hospital stay was 5.1 days (range 3 to 15 days). All patients received routine antimicrobial chemoprophylaxis with single-dose ceftriaxone 2 g intravenously immediately prior to the surgery, and average postoperative patient-controlled analgesia with buprenorphine 0.15 mg. We conclude that VATS is a very useful alternative to conventional thoracotomy in managing cases of exploration, recurrent spontaneous pneumothorax, benign pulmonary lesions, solitary pulmonary nodes, early decortications and different intrathoracic biopsies.

War injuries to the thoracic esophagus.

OBJECTIVE: Presentation of our experience in the treatment of war injuries to the thoracic esophagus at the Split University Hospital, Croatia, during the 1991-1995 wars in Croatia and Bosnia-Herzegovina. METHODS: Retrospective analysis of clinical and surgical data on patients with war injuries to the esophagus. RESULTS: Of 2494 treated injured persons, 5 patients (0.2%) had injuries to the esophagus. We performed temporary double-exclusion of the esophagus in all our patients, followed by gastric interposition after partial esophagegtomy in three patients and simple suturing with pericardial protection of the esophagus in one patient. One of our patients died after double-exclusion due to septic complications in spite of antimicrobial chemoprophylaxis regularly performed in all injured persons. Final surgical outcome and mortality rate (20%) in our patients were quite satisfactory. CONCLUSION: Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the thoracic esophagus.

War injuries of the lungs.

OBJECTIVE: The authors' experience in the treatment of war injuries of the lungs, gained during the war in Croatia, from August 25, 1991 until July 1, 1995, is presented. In that period, 424 patients with injuries of the lungs were treated at the Split Clinical Hospital. METHODS: The paper is a retrospective study of 424 wounded persons with lung injuries gained during the war in Croatia, processed by basic statistical analysis. RESULTS: Penetrating and nonpenetrating wounds were present in 331 (78.1%) and 93 (21.9%) patients, respectively. There were 407 (96.0%) men and 17 (4.0%) women. Explosive wounds were most frequent (n = 251; 59.2%), followed by gunshot wounds (n = 158: 37.3%) and other types of wounds in 15 (3.5%) patients only. Thoracotomy was performed in 89 (22.9%) patients, whereas conservative surgical methods (wound treatment, chest-tube drainage, appropriate fluid therapy, antimicrobial and atelectasis prophylaxis) were used in 300 (77.1%) patients. A great majority of the patients (n = 395; 93.2%) were discharged as fully recovered or in improved condition, 22 (5.2%) patients were referred to other institutions for further treatment, and seven (1.7%) wounded persons died. CONCLUSIONS: It is shown that most war wounds of the lungs can be successfully managed by 'conservative' surgical treatment.

Functional effects of typical lung resections for primary bronchogenic carcinoma.

In 60 patients with primary bronchogenic carcinoma undergoing surgery, pulmonary function studies were performed before, and then 10 days and 3 to 6 months after typical lung resection. Preoperative profiles showed a slight restrictive pattern without air trapping and slightly disturbed gas exchange. The restrictive pattern was not related to clinical, X-ray and endoscopy findings. The alveoloarterial oxygen gradient was smaller in the patients requiring lobectomy than in pneumonectomy patients. After surgery, the volume loss was related to the amount resected, being greater after right pneumonectomy than after left pneumonectomy, smaller after bilobectomy and the least after lobectomy. The obstructive pattern remained unchanged. Diffusion of carbon monoxide decreased significantly less than the volumes after pneumonectomy, but proportionally after lobectomy and bilobectomy. Those with increased alveoloarterial oxygen gradient or increased physiologic dead space showed a significant improvement of their gas exchange after surgery.

A war injury to the thoracic trachea.

The authors present a case of war injury to the thoracic trachea with the defect involving more than half of its circumference. After minor difficulties in establishing the right diagnosis, we passed to the surgical procedure and managed the lesion by simple suture. The patient's postoperative course at the Intensive Care Unit was uneventful. Both early and late follow-up roentgenograms, computerized tomography of the trachea and bronchoscopy showed normal findings.