599 MEDIASTINITIS SECONDARY TO ESOPHAGEAL PERFORATION: IT’S TOO LATE?

Mediastinitis secondary to esophageal perforation is a rare, progressive, and destructive disease that may often lead to an imminent risk of death. We describe a single center experience showing how early diagnosis and prompt intervention can reduce mortality and complications. Methods From February 2016 to December 2019, 15 consecutive patients were referred to the Emergency Unit of The AORN Cardarelli (Naples) with clinical and radiological (CT scan) diagnosis of acute mediastinitis secondary to oesophageal perforation (post endoscopy or after foreign body ingestion) and furthermore, referred to the Thoracic Surgery Unit, they underwent to early surgical treatment (cervicotomy and\or thoracotomy and chest drainage. Results For early detected case (occurred within 24 hours) an emergency thoracotomy/cervicotomy was performed with surgical repair. For late detected (referred from other hospitals) a Surgical esclusion (abdominal plus cervical) and toilette thoracotomy was performed in emergency. Reconstruction occurred in 5 cases with a median of 46 days after firts care. All patient were admitted to ICU unit and susbsequentily to the thoracic surgery ward. 30 days mortality occurred in two cases. Median hospital staying was 28 days, in six cases a redo surgery was necessary. Empiric antibiotic treatment was started before operation and reviewed under Infectivologist. Conclusion Mediastinitis secondary to esophageal perforation has a fulminating course with a potential risk of sepsis, pericarditis, and multiple organ failure. A prompt identification and an invasive treatment is the best and most successful option to reduce mortality and improve patient’s recovery.

Intrathoracic fracture-dislocation of the humeral head: A case report and review of the literature

Background: Intrathoracic displacement of a humeral head fracture is extremely rare. Only slightly more than 30 cases have been reported in this regard. Since few cases have been reported, there is no consensus on how to treat this injury. The etiology, injury mechanism, related lesions, and treatment of the injury are diverse. Case presentation: A 73-year-old female presented with multiple fractures of the left ribs, bilateral lung contusions, extensive emphysema of the anterior and posterior chest wall, massive left hemopneumothorax, fracture-dislocation of the proximal humerus, and intrathoracic displacement of the humeral head. The patient was sent to the operating room for emergency thoracotomy surgery. The head of the humerus was confirmed to be completely removed from the thoracic cavity during the operation. After discussion with the orthopedic surgeon, the humeral head was discarded considering avascular necrosis; moreover, open reduction and internal fixation were not performed. The orthopedic surgery team performed reverse shoulder arthroplasty three weeks later. During follow-up, the patient’s shoulder was free from pain, and its range of movement included 110° flexion, 70° abduction, 35° external rotation, and 50° internal rotation. Conclusion: Intrathoracic displacement of the humeral head due to proximal humeral fracture is a very rare and serious trauma that requires multidisciplinary treatment. Considering the extremely high risk of humeral head necrosis, actively removing broken bone fragments of the humeral head in the early stage is recommended, and we advocate for shoulder arthroplasty for elderly patients. Detailed preoperative evaluations and individualized operation plans should be made to achieve the best effect.

Intrathoracic Fracture-dislocation of the Humeral Head:A Case Report and Review of the Literature

BackgroundIntrathoracic displacement of a humeral head fracture is extremely rare.Only slightly more than 30 cases have been reported. Because few cases have been reported, there is no consensus on how to treat this injury. The etiology, injury mechanism, related lesions and treatment of the injury are diverse.Case presentationA 73-year-old woman presented with multiple fractures of the left ribs, bilateral lung contusions, extensive emphysema of the anterior and posterior chest wall, massive left hemopneumothorax, fracture-dislocation of the proximal humerus and intrathoracic displacement of the humeral head.The patient was sent to the operating room for emergency thoracotomy surgery. The head of the humerus was confirmed to be completely removed from the thoracic cavity during the operation. After discussion with the orthopedic surgeon, the humeral head was discarded considering avascular necrosis, and open reduction and internal fixation were not performed.Three weeks later, the orthopedic surgery team performed reverse shoulder arthroplasty.During follow-up, the patient’s shoulder was free from pain, and its range of movement (ROM) included 110° flexion, 70° abduction, 35° external rotation and 50° internal rotation.ConclusionsIntrathoracic displacement of the humeral head due to proximal humeral fracture is a very rare and serious trauma that requires multidisciplinary treatment. Considering the extremely high risk of humeral head necrosis, actively removing broken bone fragments of the humeral head in the early stage is recommended, and we advocate for shoulder arthroplasty for elderly patients. Detailed preoperative evaluations and individualized operation plans should be made to achieve the best effect.

Tracheoesophageal fistula with complex injury to the existing anomaly - Youngest neonate to survive: A case report

Background: Complex injury to the esophagus, trachea, and tracheoesophageal fistula in a case of esophageal atresia is rarely reported that requires prompt identification and management. Case Presentation: A very-low-birth-weight preterm with a tracheoesophageal fistula on ventilatory support for respiratory distress syndrome was transferred to our hospital. The baby developed air-leak through the tracheoesophageal fistula into the stomach causing gross distension of the stomach and reduction in oxygen saturation. Repositioning and reintubation failed to reduce the abdominal distension and to improve the saturation. Subsequent intubation with large volume, low pressure cuffed tube, and replacement of Replogle tube resulted in pneumothorax and further deterioration requiring emergency thoracotomy. Complex tracheoesophageal injury to the esophagus, trachea, and fistulous tract was repaired. Conclusion: The baby survived the early repair of the tracheoesophageal fistula and the iatrogenic complex tracheoesophageal injury. Pre-operative tracheo-esophagoscopy with stenting of the fistula with Fogarty catheter helped to carry out a successful repair technically.

Structured and Systematic Team and Procedure Training in Severe Trauma: Going from ‘Zero to Hero’ for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods

Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

Delayed postoperative bleeding following lobectomy caused by the sharp tip of a suture: a case report

Background Postoperative bleeding is a rare but serious complication occasionally caused by hard surgical materials, such as staples. Postoperative hemorrhage caused by sutures is very rare. Case presentation A 75-year-old man with lung cancer underwent right lower lobectomy. Eleven days after surgery, he developed a haemothorax. Emergency thoracotomy revealed arterial bleeding from a pinhole injury in the parietal pleura caused by a monofilament non-absorbable suture tip used during the initial surgery. Conclusions Postoperative bleeding is a serious complication, and as sutures are often used in surgery, it is important to be cautious while using this material.

Single center experience of war-related thoracic injury in Syria

Background: The Syrian civil war caused serious deaths and injuries. Thoracic surgery has shown its effectiveness in this war as it is a war surgery. In this study, we analyzed war related chest trauma patients to describe the profile of chest trauma, determine the predictors’ morbidity and mortality. Methods: From 2012 to 2017, 47 consecutive patients underwent surgical treatment for chest trauma at the Gaziantep University Sahinbey Research and Practice Hospital, in Turkey. The demographic and relevant clinical information were retrospectively collected from the hospital records. Data included mechanism of injury, gender, and age, findings, treatment modality complications, and length of hospital stay, morbidity and mortality. Injuries were classified as penetrating (gunshot or shrapnel wounds) and blunt injuries. Results: The average age of patients was 25.4 years (range, 4 to 43 years) and 40 patients were males (85%). Sadly, 6 patients were under 18 years old. There were 41 patients (%87,2) penetrating and 6 patients (%12,8) blunt injuries. The most penetrating injuries of the chest were caused by shrapnel (61,7%). Eleven patients had already had emergency thoracotomy in another hospital before admission. As multiple diagnoses, there were 50 (45,45%) pneumothorax, hemothorax, or both in patients. However, there were 26 (23,64%) lung contusions in patients. No surgery-related deaths or major morbidity occurred. One patient died 35 days after admission; the causes of death in this patient included bronchobiliary fistula, hypovolemic shock, and sepsis. So, all cases mortality rate was 2,13%. Conclusion : Intervention in thoracic trauma patients is life-saving and satisfying compared to other system injuries. War surgery is a multidisciplinary approach, which is vital.