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Mon Nov 24 11:17:08 GMT 2008

Thanks, Tim. We are also updating our series on TDH which I presented last
month at the 61st Annual Meeting of the Japanese Association for Thoracic
Surgery.

Jose Luis J. Danguilan, MD

On 11/24/08, Dr Timothy Hardcastle <dr.tchardcastle at absamail.co.za> wrote:
>
> 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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>
>
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