[Indications for emergency surgery in thoraco-abdominal injuries].

PURPOSE OF THE STUDY: Under the conditions of an increasing number of car accidents and criminal injuries the thoracis and abdominal trauma is a source of a significant morbidity and mortality in blunt and penetrating mechanism of injury. On the basis of a group of patients operated on for blunt and penetrating injury of the chest and abdomen evaluation was made of the current indication and results of lifesaving surgery in case of these injuries.

PATIENTS: The group included 68 patients requiring a lifesaving surgery for a blunt and penetrating injury of the chest and abdomen hospitalized between the beginning of 1966 and the end of April 2001. Forty-five patients sustained a blunt injury and 23 a penetrating injury.

METHODS: In case of blunt injuries the indication for surgery was determined on the basis of clinical examination supplemented with a radiograph examination of the chest and spiral computer tomography. In case of penetrating stab wounds the surgery was indicated on the basis of clinical examination, in gunshot wounds by means of x-ray examination and spiral computer tomography performed in order to assess the scope of the injury of intraabdominal organs and the location of the projectile. Indicated on the basis of the examination in the blunt injury was thoracotomy in 6 cases, laporatomy in 34 cases and the combination of thoracotomy and laparotomy in 5 patients. In case of the penetrating injury thoracotomy was performed in 8 cases, laparotomy in 11 cases and the combination of thoracotomy and laparotomy in 4 patients.

RESULTS: In the post-operative period 6 patients (9%) died: 3 patients with a polytrauma died from an irreversible damage caused by a protracted hemorrghagic shock, one female patient from the contusion of brain, one patient after splenectomy for an isolated injury died from cardiorespiratory failure and pneumonia, one patient with a stab wound of the left ventricle of the heart died from the heart failure by hypoxy.

DISCUSSION: Indication for a lifesaving thoracotomy and laparotomy in our group of patients operated on corresponds to the overviews of surgeries in thoracoabdominal injuries presented in literature. The procedure in preoperative examination is identically limited by the stability of hemodynamics in the patient after the injury using mainly ultrasound and computer tomography of the stabilized patient. In contrast to a number of authors in our conditions we have not performed some of the intervention examinations such as diagnostic peritoneal lavage or thoracoscopy and laparoscopy. The improvement of results in patients operated on for thoracoabdominal injury is in our conditions given both by the timeliness of the operation in the availability of examination methods (US, spiral CT) and by adequate stabilization of the patient in the peroperative period at the emergency department.

CONCLUSION: Priority indication for a lifesaving surgery in thoracoabdominal injuries is significant intraabdominal bleeding diagnosed on the basis of the result of the clinical examination in hemodynamically unstable patients. In a stabilized patient the lifesaving surgery is performed on the basis of the result of visualization methods (spiral computer tomography, ultrasound, angiography, endoscopy) revealing apart from significant bleeding also severe injuries of intrathoracic and intraabdominal organs. Protracted hypovolemic shock with the development of multi-organ failure or the occurrence of simultaneous severe associated injuries in polytrauma are the most frequent causes of mortality in patients operated on for thoracoabdominal injury.