ALWAYS or NEVER

Mario Gasparri, MD Division of Thoracic Surgery SSM Health – St Mary's Hospital Madison, WI

Disclosures

DuPuy Synthes – Speaker

ALWAYS - NEVER

ALWAYS or NEVER Debate

Standard Strategy when Arguing Absolutes Use misdirection and lots of pictures Present small, anecdotal clinical experiences Somewhat sketchy logic Grossly overstate my side Won’t confuse the issues with actual facts

ALWAYS or NEVER Debate

Always or Never

Bronchoscopy Thoracoscopy Chest Tubes

Always Bronchoscopy

Easy

Always Bronchoscopy

Available

Always Bronchoscopy

Safe – Morbidity in this setting should be 0%

Safe

Always Bronchoscopy

Relatively Cheap

=

Always Bronchoscopy

Easy, Available, Safe, Cheap

Does “we CAN” = “we SHOULD”?

Why do we fix rib fx/flail? …SSRF decrease pain, shortened duration of

mechanical ventilation, decreased incidence of pneumonia, decreased likelihood of tracheostomy…

Consensus Statement - Injury 2017

Always Bronchoscopy

Pain / Impaired mechanics rib fx/flail

If we are in the OR They are already somewhere on this pathway Bronchoscopy/Secretion clearance can help at any point and

prevent this pathway to death

Poor Cough

Increased Secretions

Pneumonia Respiratory Failure

Death

Always Bronchoscopy

Bronchoscopy vs “Blind” Suctioning

60% of “blind” suctioning misses the secretions

Visual suctioning has greater volume of suction retrieved

Early bronchoscopy led to better outcomes

Always Bronchoscopy

Bronchoscopy is an Easy, Available, Safe, Cheap, and Effective solution to potentially Prevent Death

Standard of care in medicine is to Prevent Death

ALWAYS perform Bronchoscopy!!

Always Thoracoscopy

Rib fractures often have associated injuries 70% Hemothorax / 20% Lung Laceration Consensus Statement - Injury 2017

At least 5 diaphragm injuries Gasparri - Personal Experience

Routine Thoracoscopy Identification of these injuries Treatment of these injuries

Always Thoracoscopy

Hemothorax Drainage

Lung Laceration Repair

Improved outcomes when other injuries addressed

Always Thoracoscopy

Aids Incision Placement/Planning

The goals of the incision…are to (1) provide adequate exposure, (2) minimize morbidity…and (3) optimize cosmesis Consensus Statement - Injury 2017

Translation Do a good job with the smallest incision possible

Always Thoracoscopy

CalorieLab 2015

Always Thoracoscopy

Always Thoracoscopy

Internal visualization allows optimal placement of incision

Smaller, targeted incision are ideal

Always Thoracoscopy

Improve VATS skills Thoracoscopic SSRF offers several theoretical

advantages…wide visualization…small incision …elimination of scapular retraction…elimination of palpable plates…increased margin on posterior fx Consensus Statement - Injury 2017

Although currently limited by available technology, it is clearly the goal and what many are working towards

Routine use of VATS will • Increase surgeon skill set • Increase comfort level/efficiency of OR crew

Always Thoracoscopy

Improves outcomes Tx of hemothorax/lung laceration/other injuries

Decreases morbidity Allows smaller incisions

Increases surgeon skills/team efficiency Repetitive use

ALWAYS perform Thoracoscopy!!

Always Chest Tubes

If you agree with ALWAYS Thoracoscopy No further discussion Chest tube placed at the

end of the procedure Game over

Always Chest Tubes Reviewed rib fx patients

1/2009-6/2013 137 Rib Stabilization pts 274 Medically Managed pts At surgery, all pts had chest

tubes placed and the pleural space irrigated

Rib stabilization with chest tube • Decreased reintervention rate • Decreased empyema rate • Decreased readmission rates

Always Chest Tubes

Agree with ALWAYS thoracoscopy Chest tube placed at the end of the case

Landmark article Routine chest tube decrease reintervention,

empyema and readmission Remember the author

Tom says so!!

ALWAYS place Chest Tubes!!