The aims of this study were to (1) define characteristics for the thoracoabdominal injury patient population; (2) describe sequences of surgical interventions with combined procedures (i.e., thoracotomy and laparotomy); and (3) describe pitfalls leading to inappropriate sequencing of surgical interventions for thoracoabdominal injuries. It was a retrospective 4-year study (January 1995 to December 1998) conducted at an urban level I trauma center. The study population comprised 254 patients who had sustained thoracoabdominal injuries requiring surgical intervention: 187 (73%) gunshot wounds (GSWs), 64 (25%) stab wounds (SWs), and 3 (2%) shotgun wounds (STWs). The mean revised (RTS) was 6.04; the mean Injury Severity Score (ISS) was 27; the mean estimated blood loss (EBL) was 3000 ml. The overall survival was 175 of 254 (69%). Of the 254, 51 (20%) underwent emergency department (ED) thoracotomy. Altogether, 73 (29%) underwent combined thoracotomy and laparotomy: 59 (81%) GSW, 13 (18%) SW, 1 (1%) STW (mean RTS 5.2, mean ISS 34, mean EBL 6800 ml). Overall survival was 30 of these 73 (41%). A total of 21 of the 73 (29%) underwent ED thoracotomy. In group I (laparotomy then thoracotomy: Lap + Thor, n = 34) the initial procedure was interrupted in 18 (53%). In group II (thoracotomy then laparotomy: Thor + Lap, n = 39) the initial procedure was interrupted in 14 (36%). Pitfalls leading to inappropriate surgical sequencing were persistent hypotension (13/73, 18%) and misleading chest tube output (8/73, 10%). It was concluded that penetrating thoracoabdominal injuries incur high mortality (31%), and the mortality doubles for patients who require combined procedures (59%). Inappropriate surgical sequencing occurred in 32 of 73 (44%) patients undergoing combined procedures. Persistent hypotension, indicating that the wrong cavity was accessed, and misleading chest tube output are the leading pitfalls in thoracoabdominal injury management.

Somatic outgrowth is seldom a primary reason for homograft conduit replacement of the right ventricular outflow tract. The most common cause for failure is conduit obstruction with thickening and shrinkage at the annular area. Conduit stenosis was responsible for failure in 53% of patients, technical issues were responsible for 30%, and only 8% failed as a result of somatic outgrowth. Placement of a smaller homograft (z = 0) at the initial operation may decrease the incidence of conduit kinking, sternal compression, and posterior shelf impingement.