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Ann Thorac Surg 1997;64:1224-1225
© 1997 The Society of Thoracic Surgeons
Marmara University Hospital, Department of Thoracic Surgery, PK 97, 81020 Acibadem, 
stanbul, Turkey
To the Editor:
We read with interest the case report by De Groot and Douie [1]. The case is introduced and discussed in detail, but we think some points should be clarified.
As we are in a developing country we also encounter such severe blunt chest trauma patients as a result of traffic accidents. In this case an 18-year-old man is said to be struck by a transit bus and to have eight rib fractures (ribs two to nine) in the right side of the chest. The patient is said to have a hemopneumothorax, and an intercostal drain was placed. Initial drainage was 1,300 mL and hemorrhagic. The patient was then placed on a ventilator and after he was weaned, he had a recurrence of pneumothorax. The patient was then operated on and the outcoming events were discussed.
For an initial approach, after 1,300 mL of hemorrhagic drainage why did De Groot and Douie not perform an exploratory thoracotomy? It is classic textbook knowledge that an initial hemorrhagic drainage of more than 1,000 mL requires an urgent thoracotomy in case of a blunt thoracic trauma [2]. We experienced a patient with a severe blunt injury to the left side of the chest with multiple fractures. After a hemorrhagic drainage of 1,200 mL following insertion of a chest tube, we performed an urgent exploratory thoracotomy. We encountered multiple rib fractures causing severe pulmonary lacerations and a large hematoma in the posterior mediastinum compressing a small aortic tear. Did De Groot and Douie think about any major vascular injury in this case?
Regarding the further handling of the patient, we think that to place a patient with multiple rib fractures on a ventilator may increase the tears on the lung surface, and this probably had a serious effect in the outcome of this patient. An exploratory thoracotomy and early pulmonary resection could have salvaged this condition.
The reason for performing such an early massive thoracoplasty and the use of a foreign body (1 L intravenous solution bag) to compress the mediastinum in a patient with Acinetobacter sepsis should also be clarified. In our clinic, we instead use crescent-shaped external stiff compresses to buttress the mediastinum in thoracoplasty cases. In De Groot and Douie's Figure 2, the first rib in the right side of the chest and transverse processes can be seen clearly, but in Figure 3 we could not see these structures. Did De Groot and Douie perform a two-stage thoracoplasty?
This case, usually a problem of developing and underdeveloped countries, is a nice introduction and may clarify some aspects in the handling of these kinds of patients.
References
Department of Cardiothoracic Surgery, University of Cape Town, Medical School, Observatory 7925, Cape Town, South Africa, e-mail: mdegroot{at}thoracic.cts.uct.ac.za
To the Editor:
I appreciate the interest in our paper and would like to reply to the points raised by Dr Batirel and colleagues.
Approximately 1,000 cases of blunt or penetrating thoracic trauma present annually to our hospital. Our indications for emergency thoracotomy take into account initial drainage but also ongoing losses, radiologic changes, magnitude of air leak, and general stability of the patient. Despite initial tube thoracostomy drainage this patient was initially hemodynamically stable with reasonable lung expansion and acceptable air leak. There were no clinical or radiologic changes to suggest major systemic vascular injury, and the major acute concern was hypoventilation due to the rib fractures and pulmonary contusion. Major lung laceration from blunt trauma is rare, and to propose exploratory thoracotomy based on initial tube thoracostomy drainage alone would result in a high number of unnecessary procedures. This notwithstanding, had an early thoracotomy been done it is possible that a resection less than a pneumonectomy would have resulted as the severe lacerations had primarily devascularized the middle and lower lobes. The initial choice of ventilation for this patient was based on respiratory distress from the rib fractures and the exploratory laparotomy. To hypothesize that ventilation can increase the physical lung injury is speculative and unsupported in the literature.
The technique of thoracoplasty was single staged despite the apparent radiologic appearances. Multistaging a thoracoplasty is pertinent to an elective scenario where spontaneous postoperative ventilation is desired. We have used external buttressing on numerous occasions in the form of sandbags, compression dressings, arm slings, or lying the patient on the operative side down to reduce paradoxical motion and reduce the residual space. As the patient was already ventilator dependent it is doubtful these would have been nearly as effective as the internal buttress. The pleural space was already contaminated, so the addition of a "foreign body" was ameliorated by draining the area. Of note, no untoward complication resulted from this.
I would not agree with Batirel and associates that this is a "problem" of developing countries. The mechanism of injury is universally common, as are the complications encountered. The solution was paradoxically facilitated by our frequent exposure to thoracoplasty in the milieu of inflammatory lung disease. In this instance I believe the favorable outcome was directly related to our broad exposure to some of the less commonly encountered aspects of the surgical art.
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