Sunday's Case

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Sorry for missing a day.  
 
Case to this point.   27yom GSW to R head of clavicle, traversing  to T4 
spine, fracturing spine and diverting into posterior  LUL.    Stable.   
Arteriogram demonstrated tiny  proximal innominate artery pseudoaneurysm from one of the 
bullet  fragments.   Barium esophagogram demonstrated extravasation at  T4.   
Debates ensued.
 
1.    Fix both lesions at same anesthesia
2.    One incision or two
3.    Patient position(s)
4.    Which thoracic incision (7 options  available)
5.    Should surgeon prepare a muscle flap upon entry  into chest to cover 
eventual esophageal injury
6.    Is this really a stentable vascular lesion, and  is there data to 
support using a stent in this particular  location.    Should this be on protocol 
or is it a standard of  practice
 
7.    If surgery is done for innominate artery what  incision
8.    Does this patient need one lung  anesthesia.   How would that be 
accomplished
9.    What sutures to use for esophageal repair
10.    Should patient have a proximal diverting  cervical esogostomy
11.    Does patient need a feeding gastrostomy
12    Now that everyone knows that he needs surgery,  does he need 
antibiotics and which should be used and for how long, if at  all
 
13.    Is there any special problems with combined  vascular and esophageal 
injuries
14.    If an anterolateral or posterolateral  thoracotomy is selected, which 
side should be cut and WHICH  INTERSPACE.   Does it make any difference
 
15.    Is it possible to suture an esophageal injury  endoscopically
16.    Is this a General SUrgery, Trauma Surgery, Acute  Care SUrgery, 
Thoracic Surgery, or Vascular surgery case.   Who should  be the primary doctor and 
write ALL the orders?   Could ONE surgeon be  the only surgeon in this case
 
17.    Following surgery should this patient go to PACU  or ICU and who 
should be his doctor.  
 
A decision was made to DELAY any surgery on the INNOMINATE  ARTERY.    The 
Radiologist said they did not have an appropriate  size match to stent the  
Innominate artery
 
SO................to the esophagus.   Several have suggested the  sequence to 
this point, but no one has told me which interspace, anterior or  posterior, 
Right or Left.   Note that on the esophagus seems to  be to the LEFT of the 
spine.    Maybe that is rotation???
 
HELP
 
k

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