The American Journal of Surgery (2013) 206, 826-833

Southwestern Surgical Congress: Edgar J. Poth Memorial Lecture

Disruptive technology in the treatment of thoracic trauma

R. Stephen Smith, M.D., R.D.M.S.*

Department of Surgery, University of South Carolina School

of Medicine, Two Medical Park Road, Suite 306, Columbia,SC 29203, USA

KEYWORDS:Trauma ultrasound;Thoracoscopy;Pulmonary tractotomy;TEVAR;Flail chest;ECMO

The author declares no conflicts of i

Edgar J. Poth Memorial Lecture, pres

of the Southwestern Surgical Congress,

26, 2013.

* Corresponding author. Tel.: 11-803

E-mail address: ssmith11@wpahs.or

Manuscript received October 15, 201

2013

0002-9610/$ - see front matter � 2013

http://dx.doi.org/10.1016/j.amjsurg.20

Abstract The care of patients with thoracic injuries has undergone monumental change over the past25 years. Advances in technology have driven improvements in care, with obvious benefits to patients.In many instances, new or ‘‘disruptive’’ technologies have unexpectedly displaced previously estab-lished standards for the diagnosis and treatment of these potentially devastating injuries. Examplesof disruptive technology include the use of ultrasound technology for the diagnosis of cardiac tampon-ade and pneumothorax; thoracoscopic techniques instead of thoracotomy, pulmonary tractotomy, andstapled lung resection; endovascular repair of thoracic aortic injury; operative fixation of flail chest;and the enhanced availability of extracorporeal lung support for severe respiratory failure. Surgeonsmust be prepared to recognize the benefits, and limits, of novel technologies and incorporate thesemethods into day-to-day treatment protocols.� 2013 Elsevier Inc. All rights reserved.

It is a great privilege to present the Edgar J. PothMemorial Lecture at the 65th Annual Meeting of theSouthwestern Surgical Congress. I have greatly enjoyedmy 30 years of involvement with this fine organization andconsider it a great honor to give the Poth lecture. Dr Poth,the 16th president of this organization, was an outstandingsurgeon and scientist. While many of the topics that Idiscuss today would be unfamiliar to Dr Poth, I am certainthat he would recognize the importance of technologicaladvances in providing outstanding care our patients.

The term disruptive technology has not been widely ap-plied to surgery and medicine. However, this term seemsparticularly applicable to the impact of new technologyon the treatment of surgical patients. The term disruptivetechnology was first coined in 1997 by Professor Clayton

nterest.

ented at the 65th Annual Meeting

Santa Barbara, California, March

-545-5802; fax: 11-803-933-9545.

g

3; revised manuscript October 15,

Elsevier Inc. All rights reserved.

13.10.004

Christenson of the Harvard Business School.1 He defineddisruptive technology as ‘‘a new technology that unexpect-edly displaces an established technology.’’ A few examplesof disruptive technology may be useful. The introduction ofthe printing press, the widespread availability of cellulartelephones, GPS [Global Positioning System] technology,television, jet aircraft, the computer chip, and many othersare examples of new technology that not only changed theworld in which we live but rapidly displaced previouslysuccessful technological methods.

My purpose today is to discuss a few examples oftechnological advancement that have, and will, dramati-cally change the way we treat patients with thoracic trauma.While there are innumerable examples that might beappropriate for discussion, I have chosen to focus on afew advances that I consider particularly significant. Theseare the eFAST [extended focused assessment with sonog-raphy for trauma] examination, the use of thoracoscopy intrauma, the lung-sparing techniques of pulmonary tractot-omy and stapled wedge resection, delayed and endovas-cular repair traumatic aortic disruption, operative fixationof rib fractures, and new miniaturized and simplifiedmodels of ECMO [extracorporeal membrane oxygenation]

Figure 1 (A) Ultrasound image demonstrating cardiac tampon-ade from a stab wound to the right ventricle. (B) Line drawing ofan ultrasound image of cardiac tamponade.

R.S. Smith Disruptive technology in thoracic trauma 827

technology. Members of the Southwestern Surgical Con-gress have provided leadership in many of these advancesin patient care.

The Extended Focused Assessment withSonography for Trauma Examination

The use of ultrasound has been embraced in the evalu-ation of injured patients by many trauma surgeons. TheFAST [focused assessment with sonography for trauma]examination for detection of fluid in the peritoneal cavity isstandard procedure at most trauma centers.2,3 This techno-logical application has largely replaced diagnostic peritoneallavage and serves as an essential adjunct to computed to-mography. The use of ultrasound for the detection cardiactamponade is widely recognized as a superior method com-pared to other techniques such as pericardiocentesis and di-agnostic pericardial window (Fig. 1). The routine use ofultrasound has facilitated the diagnosis of cardiac tampon-ade at a point much earlier in the course of patient assess-ment.2,3 The ultrasound diagnosis of tamponade isfrequently made prior to alteration of the patient’s hemody-namic status. This improvement in the diagnostic timelinehas permitted a more orderly and planned operative inter-vention for many patients with cardiac injury. There is littledoubt that this technological advance as expedited and im-proved patient care.

Recently, routine application of the eFAST examinationhas become more widespread at trauma centers. The eFASTexamination utilizes same bedside technology to providethe early diagnosis of pneumothorax.4,5 The diagnosispneumothorax by ultrasound is accomplished by using ahigh-frequency ultrasound transducer to examine the ana-tomic relationship of the pleural interface. In the presenceof a pneumothorax, there is loss of the ‘‘lung-sliding’’ find-ing and the absence of a ring-down or comet-tail artifact(Fig. 2). This technique is learned rapidly and performedquickly. The use of M-mode ultrasound further increasesthe utility of this technique. Several large series performedat prestigious level 1 trauma centers has validated sensitiv-ity, specificity, and accuracy of this technique. Dulchavskyet al4 showed that there were no false-positive examinationsin a series of 382 patients. This group reported a 95% sen-sitivity for the EFAST examination. Knudtson et al5 docu-mented that surgeon-performed eFAST had a sensitivityof 99.7%, a negative predictive value of 99.7%, and accur-acy of 99.4% compared to chest radiography. In summary,eFAST is the premier method for the detection of cardiactamponade and in some centers is replacing team conven-tional chest x-ray for the diagnosis of pneumothorax.

Thoracoscopy in Trauma

Use of minimally invasive techniques for diagnosis andtreatment dates back to the 10th century, when Abdulkasimused reflected light to examine the cervix of women. And in

the early 20th century, Jacobaeus6 first reported the utiliza-tion of ‘‘laparothorakoskopie’’ for evaluation of the pleuralcavities. Jones et al,7 at Charity Hospital in New Orleans,provided an early report demonstrating the effectivenessof thoracoscopy in the trauma setting. This group used arigid proctoscope, under local anesthetic and without endo-tracheal intubation, to perform examination of 36 patientswith traumatic hemothorax. These examinations were per-formed at the bedside in the emergency department. Theyfound that this simple technique altered the managementof 44% of their patients. They were able to achieve hemo-stasis in several patients with intercostal artery hemorrhagewith electrocautery. More recently, a number of groupshave demonstrated the benefits of thoracoscopy in evalua-tion and treatment of injured patients.8–14 As of February

Figure 2 Ultrasound image of the pleural interface. The absenceof a pneumothorax is confirmed by ‘‘lung-sliding’’ and comet tailartifact.

Figure 3 Stapled pulmonary tractotomy.

828 The American Journal of Surgery, Vol 206, No 6, December 2013

of 2013, at least 120 English-language articles have ad-dressed this topic. Wong et al8 described 41 hemodynami-cally stable patients with thoracic injury. This groupreported consistent success in the treatment of bleedingfrom intercostal artery injury, identification and repairof diaphragmatic injuries, and evacuation of retainedhemothorax. Ben-Nun et al9 recently compared the use ofthoracoscopy to traditional thoracotomy. This group dem-onstrated that patients treated with thoracoscopy had lesspostoperative pain, a shorter recovery period, and weremore likely to return to preinjury levels of activity. Milan-chi et al10 reported the successful use of thoracoscopy in 25injured patients and further reported the use of this tech-nique for the removal of a foreign body, creation of a per-icardial window, ligation of the thoracic duct, andlobectomy in addition to previously reported indications.Smith et al11 recently reported the use of thoracoscopy byan acute care surgery service for the treatment of retainedhemothorax, empyema, and persistent air leak. This groupappropriately emphasized that utilization of thoracoscopyearly in the course of treatment provided improved results.

In summary, the use of thoracoscopy in the traumasetting has both diagnostic and therapeutic utility. In thediagnostic category, thoracoscopy has been useful indetermining the cause of persistent pneumothorax, diag-nosing injuries to the intercostal arteries, the diaphragm, theheart, pulmonary parenchyma, the esophagus, and the greatvessels. Thoracoscopy has been demonstrated as an effec-tive intervention for removal of clotted hemothorax, decor-tication, treatment of persistent pneumothorax, hemorrhagecontrol, repair of the diaphragm, foreign body removal,drainage of pleural and pericardial effusions, and otherindications. In summary, thoracoscopy has largely replacedthoracotomy as front line treatment for persistent pneumo-thorax, evacuation of retained hemothorax and continuedbleeding from intercostal artery aneurysm. The indicationsfor the thoracoscopy in the trauma setting continue toexpand.

Pulmonary Tractotomy and Wedge Resection

Penetrating pulmonary injury is associated with the highrate of morbidity and mortality. A recent study performedby the Western Trauma Association multicenter trials groupdocumented progressively more extensive pulmonary re-section following injury is associated with a correspondingincrease in mortality. Therefore, techniques that achievehemostasis while preserving the maximal amount of pul-monary parenchyma are desirable. In the past, deep lobarinjuries were preferentially treated with major pulmonaryresection such as a lobectomy. A major advance in thetreatment of pulmonary penetrating injuries was introduc-tion of pulmonary tractotomy by Wall et al15 in 1994. Thisgroup showed that utilization of this straightforward tech-nique facilitated definitive control of bleeding while pre-serving long parenchyma. This approach was modified byAsensio et al16 in 1997. This group conclusively demon-strated that the use of linear stapling devices for tractotomywas not only faster but was equally effective (Fig. 3). Sub-sequently, the use of linear stapling devices to facilitate thewedge resection was found to be equally efficacious(Fig. 4).

In summary, pulmonary tractotomy is a fast and effec-tive technique for the treatment of deep lobar injuries.Tractotomy allows preservation of lung parenchyma and isassociated with lower mortality rates. This technique andwedge resection obviate the need for major pulmonaryresection in many patients. This crucial technique should bein the armamentarium of any trauma or acute care surgeon.

Delayed and Endovascular Repair of ThoracicAortic Injury

One of the most devastating injuries is that of bluntinjury to the thoracic aorta. A 10-year retrospective reviewof autopsy and clinical data reported a mortality rate of84%.17 The majority of patients with this injury die at the

Figure 4 Stapled wedge resection of the lung following a gun-shot wound.

R.S. Smith Disruptive technology in thoracic trauma 829

scene of the accident or shortly thereafter. However, manypatients arrive at trauma centers with stable vital signs. Sur-vival rates of 80% for this subgroup of patients have beenreported. It has been appropriately noted that prompt recog-nition and treatment of this injury results in acceptable ratesof morbidity and mortality. In the past, therapeutic ap-proaches included immediate operative repair with interpo-sition grafts. Operative strategies included the ‘‘clamp andsew’’ technique, the use of cardiopulmonary bypass, partialbypass techniques, and heparin-bonded shunts. These openoperative procedures, while reasonably effective, were as-sociated with significant complications and mortality. Com-plications included alarmingly high rates of postoperativeparaplegia, recurrent laryngeal nerve injury, and death. Aparadigm shift in the treatment of this injury has occurredover the past decade. Demetriades et al18 have recently de-scribed this change in philosophy in an observational mul-ticenter trial comparing early versus delayed repair ofthoracic aortic injury. In this study of 178 patients, 109 pa-tients received early repair, while 69 patients received aplanned delayed repair. An open technique was utilized in63 patients, while 115 patients underwent a TEVAR [tho-racic endovascular aortic repair] procedure. Patients under-going an early repair at a higher mortality rate (18% vs 4%,P 5 .034), while patients undergoing delayed repair andlonger ICU [intensive care unit] and hospital lengths ofstay. No differences noted in complication rates for mortal-ity rates between the 2 groups. Specifically, the rate of par-aplegia was equivalent. In 2013, Azizzadeh et al19

compared endovascular repair to open techniques. This ret-rospective study examined the course of 106 patients. Openrepair was formed in 56 patients, and 50 patients were trea-ted with an endovascular technique. Patients treated with anopen technique had higher morbidity and mortality rates.An open repair was associated with a 3 times higher oddsof complications or death. Patients that received a TEVARwere more likely to have undergone delayed management,a longer length of stay during the preoperative period, and

higher costs. This group noted that in the final year of thestudy (2010), 100% of patients had been treated as endo-vascular repair. Khoynezhad et al20 recently reported the re-sults of the RESCUE trial. This was a prospectiverandomized multicenter trial examining 30-day and 5-year outcomes for TEVAR. This study involved 20 differentcenters, and 50 patients were enrolled over a 2-year period.This group reported an all-cause mortality rate of 8% at 30days. The TEVAR was successfully deployed in 100% pa-tients. The origin of the left subclavian artery was occludedby endovascular graft placement in 40% of patients. Subse-quently, 4 patients required subclavian revascularization forsymptoms of upper extremity ischemia. No patients devel-oped either postoperative paraplegia or stroke. Five-yearfollow-up of these patients is pending, and these resultsare greatly anticipated. The TEVAR procedure for aortic in-jury is now preferred by most thoracic and vascular sur-geons. However, the long-term complications andoutcomes for this technique are not known. Areas of con-cern include progressive aortic dilatation with aging, inad-equate stent graft characteristics, stent graft durability, thecumulative radiation exposure secondary to surveillance ra-diography, and the risk of the necessary treatment of trivialaortic injuries.

In summary, the endovascular repair has largely replacedopen techniques in the treatment of thoracic aortic injury.Additionally, strategies involving planned delayed repairhave displaced the standard approach of immediate surgicalintervention. However, long-term results are needed beforeopen repair is permanently abandoned.

Operative Fixation of Rib Fractures

In the United States each year, more than 150,000patients have fractured ribs from traumatic mechanisms. Inthis population of patients, more than one third requirehospital admission, primarily for advanced methods ofanalgesia and significant associated injuries. At least 30%of patients admitted to a hospital due to rib fractures andchest wall trauma developed significant and potentially lifethreatening complications. The most prominent of thesecomplications are respiratory failure and nosocomial pneu-monia. Many of these patients do not recover. Additionally,a significant proportion of patients with rib fracturesdevelop chronic disability secondary to pain. The averagerecovery from time of injury to resumption of normalactivities is 70 days. Approximately 60% of patients withrib fractures develop chronic debilitating pain. Only about60% of patients admitted with rib fractures returned topreinjury levels of employment and activity. The signifi-cance and severity of chest wall trauma is a public healthissue that is generally unappreciated by surgeons andphysicians of other specialties.

The indications for surgical stabilization of rib fracturesare in evolution. Patients with severely displaced andoverlapping rib fractures are very likely to develop chronic

Figure 5 Operative fixation of flail chest.

830 The American Journal of Surgery, Vol 206, No 6, December 2013

pain secondary to rib and pseudoarthrosis and intercostalnerve neuralgia. Until recently, these patients were rarelyconsidered candidates for surgical correction. Anecdotalreports and some additional literature indicates that thesepatients may benefit from operative treatment. The majorityof patients undergoing operative fixation for rib fracturesare treated in the acute setting, and the primary indicationfor treatment is respiratory failure. This group of patientscan be divided into several categories. In patients with flailchest and pulmonary contusion, if ventilator weaning is notpossible after a period of support of mechanical ventilation,operative fixation of rib fractures may be useful. Addition-ally, patients who initially do not require intubation buthave progressive respiratory decline despite optimal non-surgical therapy, may benefit for from operative fixation.Another category of patients that should be considered for

Figure 6 Algorithm for the oper

operative fixation are those patients with multiple ribfractures that require thoracotomy for associated injuries.Patients that are hemodynamically unstable are not candi-dates for operative fixation of rib fractures.

Operative treatment of patients with flail chest andmultiple rib fractures is not a new concept. A number oftechniques and approaches have appeared in the surgicalliterature for the past half century. These techniques includethe use of plates, intramedullary devices such as Kirschnerwires, vertical bridging devices including the use of syn-thetic mesh, and the use of sternal wires for rib fixation. Todate, none of these techniques have proven superiority torandomized prospective trials. In fact, most of the previ-ously described techniques have fallen into disuse becauseof inconclusive results or surgeon dissatisfaction. In thepast decade, 2 novel plating systems have been introduced.Both of these systems involve the use of titanium platesspecifically designed for the fixation of rib fractures(Fig. 5). The systems have the advantage of ease of useand a very straightforward operative technique. As a result,the frequency of operative fixation of fractured ribs as in-creased exponentially in the last decade (Fig. 6).

Balci et al,21 in 2004, reported their group’s experiencewith 64 patients with flail chest who required mechanicalventilation. In this retrospective nonrandomized trial span-ning 9 years, 27 patients received operative management,while the remainder received continued medical therapy.The operative group appeared to have improved results out-comes, as evidenced by a decrease in the number of days ofmechanical ventilation, a decreased length of stay, de-creased morbidity, and decreased mortality. In 1 of thefew randomized prospective trials of operative fixation, Ta-naka et al22 reported their experience with 37 patients withflail chest. In this well-designed randomized trial, all

ative treatment of flail chest.

Figure 7 Pumpless extracorporeal lung support for respiratoryfailure with the NovaLung device.

R.S. Smith Disruptive technology in thoracic trauma 831

patients initially received standard medical management,including mechanical ventilation, for 5 days. After 5days, if patients could not be weaned from ventilator sup-port, they were randomized to either a surgical treatmentgroup or a group that received continued medical manage-ment. The surgical surgically treated group was found tohave a lower incidence of pneumonia, a decrease in thenumber of days of mechanical ventilation, a decrease inICU length of stay, and improved pulmonary functions1 month after discharge.

Althausen et al23 recently reported on a 5-year experiencewith 50 patients with flail chest. In this retrospective study,the mean follow-up was 18 months. Twenty-two patients re-ceived operative management based on the assessment andpreference of the surgical team that included both traumasurgeons and orthopedic surgeons. Locking plates (2.7mm) were utilized for rib fixation. The operative group ap-peared to have better outcomes. The group treated with fix-ation had fewer ICU days, a shorter period of mechanicalventilation, a decreased length of hospitalization, requiredtracheostomy less frequently, had a lower rate of pneumonia,were less likely to require reintubation, and had decreasedrequirements for supplemental oxygen at the time of dis-charge. This group reported no operative complications.

Slobogean et al24 recently performed a meta-analysis ofoperative versus nonoperative management of flail chest.This group reviewed 11 manuscripts that included datafrom 753 patient records. This analysis appeared to favoroperative management. Patients treated with operative fixa-tion had fewer days of mechanical ventilation, decreasedrates of pneumonia, a shorter ICU length of stay, a lowermortality rate, a decreased incidence of sepsis, fewer tra-cheostomies, and decreased chest wall deformity. Thisgroup concluded, ‘‘Surgical fixation may have substantialbenefits, but additional randomized prospective trials arestill necessary.’’

In summary, there has been an exponential increase inthe utilization of operative techniques for the fixation of ribfractures, despite the paucity of randomized prospectivetrials. This treatment modality may be a good option forpatients with chronic pain secondary to pseudoarthrosis orin patients with severely displaced rib fractures. Furtherrandomized prospective trials are sorely needed to delineatethe most appropriate utilization of this operative technique.

Advances in Extracorporeal MembraneOxygenation and Pumpless ExtracorporealLung Assist

I have had the honor and privilege of visiting the UnitedStates military hospital at Landstuhl, Germany, on severaloccasions. The period of time that I spent as a seniorvisiting surgeon at this excellent facility is 1 of the mostmeaningful experiences of my career. The men and womenwho staff the hospital are the finest group of medicalprofessionals that I have ever had the pleasure of meeting.

Landstuhl Regional Medical Center [RMC] is an AmericanCollege of Surgeons–verified level 1 trauma center andtertiary care facility. Landsthul RMC has the responsibilityof providing state-of-the-art trauma care for our men andwomen injured in the conflicts in Iraq and Afghanistan,after initial lifesaving treatment is provided in thosetheaters of operations. During 1 of my visits to Landstuhl,I had the opportunity to review the medical record of adesperately injured soldier who received outstanding treat-ment, not only during the early phases of care but alsoduring a long distance, intercontinental transport andsubsequent definitive interventions. This man had sufferedextensive combat-related injuries that caused severe respi-ratory failure. All conventional approaches to treatment ofhis respiratory failure had been inadequate and unsuccess-ful. In an extraordinary effort to save this young man’s life,he was placed on a novel device that provided extracorpo-real lung support. After a prolonged course of extensivetreatment, including extracorporeal lung support duringtransport and subsequently at Landstuhl RMC and Regens-berg University Hospital, this man recovered from thesedevastating injuries. This extraordinary care was the resultof close and productive collaboration between militarysurgeons and intensivists and the lung rescue team atRegensburg University Hospital, also in Germany. Withoutthe use of extracorporeal lung support, this patient wouldhave certainly succumbed to respiratory failure. Thisremarkable case provides an excellent example of theadvances in technology that now make extracorporeallung support strategies feasible in a variety of clinicalsettings.

ECMO may be described as an extracorporeal devicethat provides cardiac or respiratory support. The use ofextracorporeal membrane oxygenation techniques in thetreatment of injured patients began in 1972, when Hill25

832 The American Journal of Surgery, Vol 206, No 6, December 2013

first reported the use of this therapeutic modality for ayoung man with posttraumatic ARDS [acute respiratorydistress syndrome]. In the 1970s, ECMO devices were es-sentially cardiopulmonary bypass machines. Subsequently,in 1977, Bartlett26 reported the first series of 28 patientswith ARDS treated with ECMO. This group of patients in-cluded 14 adults and 14 children. In this severely ill groupof patients, 5 of 28 survived with support from ECMO. Allwould have expired otherwise. Unfortunately, an initial ran-domized controlled trial reported in 1979 did not demon-strate a survival advantage. Since that time, ECMO andrelated techniques have been used at a limited number oftrauma centers for the purpose of lung assist and lung res-cue therapy for respiratory failure secondary to trauma,postoperative ARDS, and some influenza strains, such asH1N1. Despite the impressive anecdotal experience of sev-eral unexpected survivors, the literature remains inconclu-sive and up to this time has demonstrated minimal ormixed survival benefit. However, recent technological ad-vances have resulted in simplification and miniaturizationof several extracorporeal support devices. For example,the Novalung iLA is a compact gas-exchange system thatdoes not include an extrinsic pump (Fig. 7). In this system,blood flow through the extracorporeal circuit is powered bythe patient’s cardiac output and blood pressure. This deviceis completely self-contained, aside from an external sourceof oxygen. A polymethylpentene hollow-fiber diffusionmembrane provides effective gas exchange. Due to relianceon the patient’s cardiac output, the device is more effectivefor correcting hypercarbia as compared to hypoxia. The en-tire system is bonded with high–molecular weight heparin,which prevents clot formation and greatly reduces the needfor systemic anticoagulation. Utilization has been furthersimplified by the availability of percutaneously placed fem-oral arterial and venous catheters that are usually placedwith ultrasound guidance. Devices such as this have ledto the concept of pumpless extracorporeal lung support.Other miniaturized ECMO devices with extrinsic centrifu-gal pumps are now commercially available.

Bein et al27 recently described the use of portableextracorporeal lung support for the treatment of severerespiratory failure in 10 combat casualties. This collabo-rative effort from Landstuhl Regional Medical Centerand the Regensberg University Hospital provided extra-corporeal support for a total of 10 patients, includinglong-distance aeromedical transport. All of these patientshad severe ARDS, and all other conventional interven-tions for respiratory failure had failed to stabilize therespiratory status of these patients. In addition to extra-corporeal lung support, a lung protective ventilator strat-egy was utilized. In all 10 cases, hypoxia and hypercarbiaimproved dramatically. The mortality rate for this high-risk group of patients was only 10%. One patient diedsecondary to multiple-system organ failure. This groupconcluded that extracorporeal lung support should beconsidered in severe respiratory failure secondary totrauma.

Haneya et al28 recently published their initial experiencewith a portable ECMO device for severe respiratory failurein an adult population. In this series, 22 patients with severeARDS were treated with this device. In 15 patients, vascu-lar access and initiation of extracorporeal lung support wereinitiated at the referring hospital prior to transportation tothe regional lung rescue center. Lung protective ventilatorstrategies were used. This group reported an immediate im-provement in both hypoxia and hypercarbia in all patients.The median duration of extracorporeal support was 13 days(range: 8 to 19 days). There were no device-related compli-cations, and 73% of patients were weaned from ECMO.The survival rate was 68%. In nonsurvivors, multiple-system organ failure and sepsis were the causes ofmortality.

Percutaneous extracorporeal lung assist approaches havealso been used to facilitate thoracic operations in patientswith severely compromised respiratory function. Wiebeet al29 reported their experience in 10 patients who requiredcomplex thoracic operations but who, because of circum-stances such as contralateral pneumonectomy, planned tra-cheal resection, severe bronchopleural fistula and acontralateral bronchial stump leak, would not tolerate con-ventional operative or anesthetic approaches. Using extra-corporeal lung support, all 10 patients had successfulcompletion of their operative procedures. In 6 patients,there was discontinuation of ventilation during the opera-tive procedure. In the remaining 4 patients, ARDS hadmade standard ventilatory techniques ineffective. In allcases, hypoxia and hypercarbia were controlled or were im-proved, even during extended periods of apnea.

In summary, recent advances in technology have re-sulted in the simplification and miniaturization of extra-corporeal membrane oxygenator systems. These advanceshave, for the first time, provided truly portable extracorpo-real lung support capability that is applicable to theinterfacility transport setting. Additionally, intraoperativesupport for complex thoracic operative procedures inpatients with severely compromised pulmonary functionis a growing reality. Results of recent trials with contem-porary ECMO and PECLA [pumpless extracorporeal lungassist] technology are impressive, but not conclusive. Theneed for additional randomized controlled trials utilizingcurrent technology is obvious. We may be on the verge ofan altered paradigm and new treatment algorithms for thetreatment of posttraumatic respiratory failure.

Conclusions

Technological innovations and novel applications ofexisting technology have markedly altered the therapeuticapproach to the treatment of common thoracic injuries.Many of these changes were unexpected or unplanned.Surgeons who care for injured patients, through thoughtfulconsideration, have driven the development of improvedmethods of treatment. With the accelerated introduction of

R.S. Smith Disruptive technology in thoracic trauma 833

new technology, long established paradigms of care arelikely to be ‘‘disrupted’’ at an equally rapid pace.

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