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Fri Jan 26 22:17:26 GMT 2007

Very interesting case;

Dr Hardcastle, you seem to be confident in stentsDo you have concerns over the long term patency of such stents in this young patient, and will he have to would you put him on any antiplatelet therapy, because if he has to, he probably won't take them (judgement from the description Dr. Mattox has made of the patient and general penetrating trauma population!).

50% penetrating trauma... don't have that here!  Makes for rather nice cases!

I'm eager to see what people would do with innominate artery if they chose one-time repair in this contaminated case... or is repair indicated?

JP Arsenault

----- Original Message ----
From: "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Friday, January 26, 2007 12:13:24 AM
Subject: RE: Sunday's Case

Ken

I'll bite: Remember my comments from the context of my practice: South Africa - most trauma general surgeons do regularly work in the chest due to our high penetrating trauma load (50%)

See my comments between your questions

-----Original Message-----
1.    Fix both lesions at same anesthesia
Yes - stent and R-posterolateral thoracotomy (re question 3/4)
2.    One incision or two
One, provided the innominate is stented - otherwise sternotomy and vascular repair first then RLT
5.    Should surgeon prepare a muscle flap upon entry  into chest to cover 
eventual esophageal injury
No - we use a pleural flap
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
Yes: See my previous post with references - we consider this safe practice and standard in our centre for STABLE injuries, with minimal consequences in the context of other injuries 
7.    If surgery is done for innominate artery what  incision
Sternotomy
8.    Does this patient need one lung  anesthesia.   How would that be 
accomplished
Have double-lumen tube in, only go onto one-lung if have problems visualising inside the chest
9.    What sutures to use for esophageal repair
I use 3/0 PDS, single layer
10.    Should patient have a proximal diverting  cervical esogostomy
If within 24hours of injury - NO
11.    Does patient need a feeding gastrostomy
Not routine in our practice - we place an NGT through the repair and feed from day 2 post-op; we don't see higher leak rates in this otherwise young/healthy group
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
As a rule in Trauma - prophylaxis at incision and X24 hours; we would use either Augmentin ,2g X3 alone or Cephuroxime 1,5g and Metronidazole 500mg X3
13.    Is there any special problems with combined  vascular and esophageal 
injuries
Not if adequate wash-out / debridement is performed in the oesophagus
14.    If an anterolateral or posterolateral  thoracotomy is selected, which 
side should be cut and WHICH  INTERSPACE.   Does it make any difference
I would go right-sided 4th or 5th interspace,posterolateral - as the oesophagus lies sub-pleural and to the righ till about 10cm above the hiatus 
15.    Is it possible to suture an esophageal injury  endoscopically
I have no idea - but I wouldn't think so!!!
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
Ken - this really depends on te individual center's set-up. For us our trauma / vascular unit shares an Academic head (my immediate boss) Danie du Toit, who is an endovascular wizz (see the previously referenced publications) and we all feel comfortable in the chest, so we (Trauma Surgery) would likely do it all, whereas if it was just the oesophagus without a vascular injury then Thoracic may be given the option, for experience sake of their residents as they don't see these often - we will remain involved. But yes, one surgeon could be the only surgeon - if other support was lacking!
17.    Following surgery should this patient go to PACU  or ICU and who 
should be his doctor.
ICU - should be electively ventilated for 12 hours, then standard weaning and ICU care; in our hands this is a combined intensivist-anaesthetist and trauma-intensivist (me) led unit. 

Again just my thoughts
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

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