Resuscitation thoracotomy.

Resuscitation thoracotomy is a rarely performed procedure whose use, in France, remains marginal. It has five specific goals that correspond point-by-point to the causes of traumatic cardiac arrest: decompression of pericardial tamponade, control of cardiac hemorrhage, performance of internal cardiac massage, cross-clamping of the descending thoracic aorta, and control of lung injuries and other intra-thoracic hemorrhage. This approach is part of an overall Damage Control strategy, with a targeted operating time of less than 60minutes. It is indicated for patients with cardiac arrest after penetrating thoracic trauma if the duration of cardio-pulmonary ressuscitation (CPR) is <15minutes, or <10minutes in case of closed trauma, and for patients with refractory shock with systolic blood pressure <65mm Hg. The overall survival rate is 12% with a 12% incidence of neurological sequelae. Survival in case of penetrating trauma is 10%, but as high as 20% in case of stab wounds, and only 6% in case of closed trauma. As long as the above-mentioned indications are observed, resuscitation thoracotomy is fully justified in the event of an afflux of injured victims of terrorist attacks.

Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture.

OBJECTIVE: Retrospective evaluation of long term results after direct suture repair of chronic traumatic aneurysm of the aortic isthmus. METHODS: From March 1979 to June 1998, a total of 19 patients with chronic traumatic aneurysm of the aortic isthmus were operated on, among whom 12 (63%) underwent direct suture. These 12 patients (age ranging from 19 to 68 years; mean 34.2 years) constitute the subject of this study. All but one suffered traffic accidents. Mean delay between trauma and surgery was 4 years (range 3 months to 12 years). All patients underwent a left posterolateral thoracotomy through the fourth intercostal space. Extracorporeal circulation for spinal cord protection was installed in six patients (five ilio-iliac shunts, one atrio-iliac shunt). Aortic rupture was partial in five and circumferential in seven patients. The mean clamping time was 25 min. The absence of loss of aortic substance and a careful mobilization of the aorta made the repair by direct suture easier; this technique could thus be achieved in 63.2% of all 19 patients operated on of chronic traumatic aneurysm within the same period. RESULTS: There was no in-hospital death and no postoperative paraplegia. With a median follow-up of 15 years 3 months (ranging from 22 to 10 years), there were no late complications. Chest X-ray was normal in all patients; eight of them underwent a control angiography between 18 and 72 postoperative months; all these angiographies but one (20% stenosis without gradient) demonstrated a normal appearance of aortic isthmus. CONCLUSION: Direct suture for repair of chronic traumatic thoracic aneurysm is a safe procedure: long-term outcome was excellent and the complications observed with prosthetic grafts or with aortic endoprosthetic stent-grafts were avoided.

[Mortality from iatrogenic esophageal perforations is high: experience of 54 treated cases]. / La mortalité des perforations instrumentales de l'oesophage est élevée: expérience de 54 cas traités.

OBJECTIVE: To underline the severity of instrumental esophageal perforations and to discuss their management. PATIENTS AND METHODS: Data from patients treated for instrumental esophageal perforation were collected retrospectively from 1980 to 1995 then prospectively since 1995 to 2000. RESULTS: Fifty-four patients were treated for instrumental perforations. Perforation occurred after exploratory endoscopy (n = 24), endoscopic dilation (n = 13), attempted tracheal intubation (n = 5), foreign body extraction (n = 5), treatment of esophageal varices (n = 4), trans-esophageal echocardiography (n = 2), and duodenal prosthesis implantation (n = 1). Clinical manifestations were immediate in 18 cases and delayed in all others, with an interval before treatment ranging from 2 hours to 45 days (mean = 70 hours). All patients were operated after large spectrum antibiotherapy and intensive care, except 3 who were treated medically due to their poor general condition. Fourteen (26%) patients died, including the 3 non-operated ones. CONCLUSION: Instrumental esophageal perforations are associated with a high mortality, probably due to the poor general condition of the patients. Diagnosis of these perforations is often delayed. A good experience of endoscopic maneuveurs and adequate post-endoscopic monitoring could allow earlier surgical treatment with lower mortality.