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Mon Nov 24 06:25:44 GMT 2008

Jose

Currently NOT YET in press - we are busy writing up. The other recent
publications to look at were in Injury (R Adams Cowley) and the older
publication from LAC in J Trauma.

Tim
Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Lecturer UKZN Dept Surgery
Deputy Director - IALCH Trauma Service

> Dear Dr. Hardcastle,
>
> Our group also has a series on TDH (traumatic diaphragmatic hernia) with
> time from initial injury of up to 20 years. We also had one patient
> falling
> on an exposed nail hitting the lower lateral chest developing TDH 10 years
> later. Fortunately, most of them present with bowel incarceration, not
> strangulation but we had 1 postoperative death ---septicemia from
> perforated
> transverse colon in the chest.
>
> We have the same views on this. I would be interested in your paper (in
> press). What journal did you submit your paper?
>
> Thanks.
>
> Jose Luis J. Danguilan, MD
> Division of Thoracic and CV Surgery
> Philippine General Hospital
>
> On 11/23/08, Dr Timothy Hardcastle <dr.tchardcastle at absamail.co.za> wrote:
>>
>> Norm
>>
>> it is exactly this group - the survivors of the 24 hour observation that
>> with penetrating trauma can have an occult injury to the diaphragm. If
>> they have a lower left chest stab, no signs of abdominal injury and
>> maybe
>> only a PTx or Htx then the risk for an occult hole in the diaphragm is
>> still high. With a 50% mortality if they present late with dead colon in
>> the chest (I've seen one 18 years after a minor stab chest with a simple
>> PTx treated with a chest tube and then discharged - no abdominal signs
>> at
>> the time; dead colon thru a small diaphragm hole) I feel this is worth
>> the
>> effort in this group.
>>
>> Up to 30% of such patients had a hole in the diaphragm on either VATS or
>> Lap-scope despite NO clinical findings. Our own series (currently not
>> yet
>> in press) found the same as the series by Demetriades and the recent
>> Injury publication from Cowley.
>>
>> Don't get me wrong - I am not saying this is to be part of the INITIAL
>> assessment, this is for later definitive treatment. There we agree -
>> clinical management first, with directed imaging
>>
>> Tim
>> Dr T C Hardcastle
>> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
>> Principal Specialist Trauma Surgeon /
>> Honorary Lecturer UKZN Dept Surgery
>> Deputy Director - IALCH Trauma Service
>> > Tim
>> >
>> > Yes it *can* be an indication but *should* it? A hole in the diaphragm
>> > is just like a hole in the peritoneum from any other direction. This
>> is
>> > violation of the peritoneum, it is not sign of repairable injury. I
>> have
>> > not read those studies for a while, but using identification of
>> > "repairable injury" as a positive outcome and no "repairable injury"
>> as
>> > a negative outcome, I do not believe that they showed any different
>> > outcome than did Nance or Shafton. This would make the general
>> > anesthesia and the insertion of the laparoscopy an unnecessary
>> > operation.
>> >
>> > And Yes, I know that many of today's surgeons (or at least this is
>> true
>> > of the younger surgeons in the US), can (will) no longer do effective
>> > abdominal examinations, and they VOMIT, but that does not make the
>> > principle incorrect
>> >
>> > Use the indications that Nance described. 1) significant blood loss =
>> > uncontrolled hemorrhage, 2) acute abdomen = hole in the GI tract go to
>> > the OR  for a laparotomy. Otherwise after 24 hours of observation with
>> > *serial physical examinations*, if neither #1 or #2 have developed
>> then
>> > discharge home without any operation
>> >
>> > Norman
>> >
>> > Norman McSwain Jr, MD FACS
>> > Trauma Director Charity Hospital
>> > Professor of Surgery
>> > Tulane University School of Medicine
>> > 504 988 5111
>> >
>> >
>> > -----Original Message-----
>> > From: trauma-list-bounces at trauma.org
>> > [mailto:trauma-list-bounces at trauma.org] On Behalf Of Dr Timothy
>> > Hardcastle
>> > Sent: Saturday, November 22, 2008 12:12 PM
>> > To: Trauma &amp; Critical Care mailing list
>> > Subject: RE: Laparoscopy in trauma
>> >
>> >
>> >> There is very little if any use for the laparoscopy in the primary
>> >> assessment and management of either blunt or penetrating trauma of
>> the
>> >> abdomen.
>> >>VATS is different. It can be used for the management of hemorrhage in
>> >> most chest injuries. It can be used to identify diaphragmatic
>> >> perforation ( and the potential need for a laparotomy). And it is
>> >> cheaper in complications, time and money than a thoracotomy
>> >>
>> >> The chest and abdomen are two different cavities, two different types
>> > of
>> >> problems tow different kinds of complications and two different
>> >> outcomes. Do not try to compare these in the same thought process
>> >>
>> >> Norman
>> >>
>> >> Norman McSwain Jr, MD FACS
>> >> Trauma Director Charity Hospital
>> >> Professor of Surgery
>> >> Tulane University School of Medicine
>> >> 504 988 5111
>> > Norm
>> >
>> > Maybe one place for lap-scope is where VATS not available and there is
>> > lower left chest stab (not GSW) looking for occult diaphragm injury.
>> At
>> > least three large series supporting this.
>> >
>> > Tim
>> > Dr T C Hardcastle
>> > M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
>> > Principal Specialist Trauma Surgeon /
>> > Honorary Lecturer UKZN Dept Surgery
>> > Deputy Director - IALCH Trauma Service
>> >
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>>
>>
>>
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