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Al Tannir AH, Biesboer EA, Golestani S, Tentis M, Maring M, Gellings J, Peschman JR, Murphy PB, Morris RS, Elegbede A, de Moya MA, Carver TW. Thoracic cavity irrigation prevents retained hemothorax and decreases surgical intervention in trauma patients. J Trauma Acute Care Surg 2024; 97:90-95. [PMID: 38523131 DOI: 10.1097/ta.0000000000004324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy (TT) for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention. METHODS We performed a single-center retrospective study from 2017 to 2021 at a Level I trauma center, comparing bedside thoracic cavity irrigation via TT versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted. RESULTS A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs. 30%, p = 0.03) and less likely to have a flail chest (10% vs. 21%, p = 0.01). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs. 19%, p < 0.001) and retained HTX (10% vs. 21%, p < 0.001). The irrigated cohort had a shorter TT duration (4 vs. 6 days, p < 0.001) and hospital length of stay (7 vs. 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (adjusted odds ratio, 0.37; 95% confidence interval [CI], 0.30-0.54), retained HTX (adjusted odds ratio, 0.42; 95% CI, 0.25-0.74), and a shorter TT duration ( β = -1.58; 95% CI, -2.52 to -0.75). CONCLUSION Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Abdul Hafiz Al Tannir
- From the Division of Trauma and Critical Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Ouwerkerk JJJ, van Ee EPX, Brown TA, Dorken-Gallastegi A, Gebran A, Argandykov D, Proaño-Zamudio JA, Hwabejire JO, Kaafarani HMA, Velmahos GC, Parks J. Video-Assisted Thoracic Surgery Evacuation of Retained Hemothorax; Timing May Not Increase Thoracoscopic Failure. J Surg Res 2024; 293:168-174. [PMID: 37774594 DOI: 10.1016/j.jss.2023.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/30/2023] [Accepted: 07/23/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Current guidelines for retained hemothorax (rHTX) in trauma patients recommend video-assisted thoracic surgery (VATS) within 4 days. However, this recommendation is currently based upon evidence from small observational studies. The aim of this study is to further evaluate the association between timing of VATS and clinical outcomes in rHTX following trauma. METHODS Using the 2017-2019 Trauma Quality Improvement Program database, adult (≥15 years-old) trauma patients with rHTX who underwent evacuation of rHTX through VATS were included. Multivariable linear and logistic regression were used to evaluate the association between the timing of VATS and clinical outcomes. Postponing/delaying evacuation through VATS was defined in our analysis as performing the surgery 1 day later in time. RESULTS 793 patients were included. VATS was performed at a median 4.5 days (Interquartile range = 2.4, 8.4). A 1.17 day increase in hospital length of stay (P = <0.001), a 0.17 day increase in postoperative hospital length of stay (P = 0.007), a 0.48 day increase in ventilation days (P = <0.001), and a 0.66 day increase in intensive care unit length of stay (P = <0.001) was found for each day that VATS was delayed. Additionally, a 1.10 odds ratio for infectious complications (P = <0.001) and a 0.96 odds ratio for discharge to home (P = 0.006) was seen for each day VATS was delayed. There was no significant association between the timing of VATS failure of VATS (defined as requiring additional procedures such as a secondary VATS or progressed to thoracotomy after initial VATS) and mortality (P > 0.05). CONCLUSIONS While delaying VATS was statistically associated with increased hospital length of stay, and other secondary outcomes, the clinical significance of the increase in these variables were less dramatic compared to the results of other studies, thus tempering the urgency of evacuation. Additionally, there was no association found between the timing of VATS and mortality, discharge disposition, or the need for additional VATS and/or thoracotomy. Therefore, in the appropriate clinical context, the evacuation of rHTX through VATS can be delayed if clinically necessary, without an associated increase in mortality or the requirement for additional procedures.
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Affiliation(s)
- Joep J J Ouwerkerk
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Trauma Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Elaine P X van Ee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Trauma Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Tommy A Brown
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Krämer S, Graeff P, Lindner S, Walles T, Becker L. [Occult and Retained Haemothorax - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Trauma Society (DGU - Section NIS) and the German Society for Thoracic Surgery (DGT)]. Zentralbl Chir 2023; 148:67-73. [PMID: 36470289 DOI: 10.1055/a-1972-3352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of occult and retained haemothorax is challenging for all involved in the care of polytrauma patients in terms of diagnosis and treatment. The focus of decision making is preventing sequelae such as pleural empyema and avoiding a trapped lung. An interdisciplinary task force of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU) on thoracic trauma offers recommendations for post-trauma care of patients with occult and/or retained haemothorax, as based on a comprehensive literature review.
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Affiliation(s)
- Sebastian Krämer
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Pascal Graeff
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Sebastian Lindner
- Klinik für Thoraxchirurgie und thorakale Endoskopie, HELIOS Klinikum Erfurt, Erfurt, Deutschland
| | - Thorsten Walles
- Klinik für Herz- und Thoraxchirurgie, Abteilung Thoraxchirurgie, Otto-von-Guericke-Universität Magdeburg Medizinische Fakultät, Magdeburg, Deutschland
| | - Lars Becker
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
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Risk Factors for Retained Hemothorax after Trauma: A 10-Years Monocentric Experience from First Level Trauma Center in Italy. J Pers Med 2022; 12:jpm12101570. [PMID: 36294709 PMCID: PMC9605043 DOI: 10.3390/jpm12101570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/02/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
Thoracic trauma occurs in 20–25% of all trauma patients worldwide and represents the third cause of trauma-related mortality. Retained hemothorax (RH) is defined as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with a thoracic tube. The aim of this study is to investigate risk factors for the development of RH in thoracic trauma and predictors of surgery. A retrospective, observational, monocentric study was conducted in a Trauma Hub Hospital in Milan, recording thoracic trauma from January 2011 to December 2020. Pre-hospital peripheric oxygen saturation (SpO2) was significantly lower in the RH group (94% vs. 97%, p = 0.018). Multivariable logistic regression analysis identified, as independent predictors of RH, sternum fracture (OR 7.96, 95% CI 1.16–54.79; p = 0.035), pre-admission desaturation (OR 0.96; 95% CI 0.77–0.96; p = 0.009) and the number of thoracic tube maintenance days (OR 1.22; 95% CI 1.09–1.37; p = 0.0005). The number of tubes placed and the 1° rib fracture were both significantly associated with the necessity of surgical treatment of RH (2 vs. 1, p = 0.004; 40% vs. 0%; p = 0.001). The risk of developing an RH in thoracic trauma should not be underestimated. Variables related to RH must be taken into account in order to schedule a proper follow-up after trauma.
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Factors Associated With Successful Video-Assisted Thoracoscopic Surgery for Traumatic Hemothorax in Children: A Cross-Sectional Study. J Surg Res 2022; 279:748-754. [PMID: 35940051 DOI: 10.1016/j.jss.2022.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 06/13/2022] [Accepted: 06/29/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Due to the rarity of traumatic hemothorax in children, no studies have evaluated factors associated with successful video-assisted thoracoscopic surgery (VATS) as definitive management. METHODS We conducted an exploratory cross-sectional analysis of pediatric patients in the Trauma Quality Programs database from 2008 to 2017 with traumatic hemothorax managed with primary VATS. Those with early resuscitative thoracotomy for cardiac arrest were excluded. We stratified patients by blunt or penetrating mechanism and estimated absolute differences (ADs) and 95% confidence intervals (CIs) to identify factors associated with successful VATS without conversion to thoracotomy or reoperation. RESULTS A total of 293 patients were eligible. Among 184 penetrating injuries, 150 (82%) underwent successful VATS, 6 (3%) required reoperation, and 28 (15%) converted to thoracotomy. Diaphragmatic injuries (AD = -28, 95% CI = -46 to -10) and rib fractures (AD = 12, 95% CI = 1 to 23) had the strongest negative and positive associations (respectively) with successful VATS. There were 109 blunt injuries: 86 (79%) underwent successful VATS, 6 (6%) required reoperation, and 17 (16%) converted to thoracotomy. Moderate or severe head injury (AD = -15, 95% CI = -32 to 2), injury severity score >15 (AD = -19, 95% CI = -33 to -5), and the presence of diaphragmatic injury (AD = -38, 95% CI = -71 to -4) had the strongest negative associations with successful VATS. CONCLUSIONS Some children with traumatic hemothorax can be successfully managed with VATS. For penetrating mechanism, diaphragmatic injuries were associated with less success, while rib fractures were associated with more success. For blunt mechanism, diaphragmatic injuries, injury severity score >15, or moderate or severe head injury were associated with less success.
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Zambetti BR, Lewis RH, Chintalapani SR, Desai N, Valaulikar GS, Magnotti LJ. Optimal time to thoracoscopy for trauma patients with retained hemothorax. Surgery 2022; 172:1265-1269. [PMID: 35868904 DOI: 10.1016/j.surg.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/13/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set. METHODS Patients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden's index was then used to identify the optimal time to VATS. RESULTS From the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43-0.63, P < .0001). CONCLUSION Patients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.
| | - Richard H Lewis
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | | | - Nidhi Desai
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Ganpat S Valaulikar
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Louis J Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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Grant HM, Knee A, Tirabassi MV. Factors Associated with Successful Video-Assisted Thoracoscopic Surgery and Thoracotomy in the Management of Traumatic Hemothorax. J Surg Res 2021; 269:83-93. [PMID: 34534856 DOI: 10.1016/j.jss.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/11/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Few studies have identified factors associated with successful VATS or thoracotomy as the initial operative strategy among patients with traumatic hemothorax. MATERIAL AND METHODS We performed an exploratory analysis using the 2008 to 2017 TQP database. We identified all patients aged 18 to 89 years with traumatic hemothorax who were treated with tube thoracostomy alone in the first 24-hours of admission, followed by VATS or thoracotomy. Logistic regression was used to identify factors associated with successful VATS (no conversion or reoperation) or thoracotomy (no reoperation) as the initial operative strategy. RESULTS Among 2052 patients managed with initial VATS after chest tube drainage, 1710 (83%) were successful, while 263 (13%) were converted to thoracotomy and 79 (4%) required reoperation. On multivariable analysis, poor GCS (OR = 0.96 [95% CI = 0.94-0.99]), major injury (OR = 0.69 [95% CI = 0.53-0.90]), and diaphragmatic injury (OR = 0.42 [95% CI = 0.30-0.60]) were associated with lower odds of successful VATS, while rib fractures (OR=1.29 [95% CI=1.01-1.66]) were associated with higher odds of success of the initial operative plan. Among 3486 patients initially managed with thoracotomy after drainage with tube thoracostomy, 3118 (89.4%) were successful, while 11% (n = 368) required reoperation. Multivariable analysis revealed that major injury (OR = 0.68 [95% CI = 0.50-0.92]), blunt mechanism (OR = 0.63 [95% CI = 0.50-0.78]), and diaphragmatic injury (OR = 0.67, 95% CI = 0.53-0.84]) were associated with lower odds of successful thoracotomy as the initial operative plan. CONCLUSIONS More severe injuries and diaphragmatic injuries have lower odds of successful of VATS or thoracotomy as the initial operative management strategy among patients with traumatic hemothorax. Rib fractures may be associated with higher odds of success of VATS as the initial management strategy.
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Affiliation(s)
- Heather M Grant
- Department of Surgery, UMass Medical School - Baystate, Springfield, MA; Institute for Healthcare Delivery and Population Science, UMass Medical School - Baystate, Springfield, MA.
| | - Alexander Knee
- Office of Research, Epidemiology/Biostatistics Research Core, Baystate Medical Center, Springfield, MA; Department of Medicine, UMass Medical School - Baystate, Springfield, MA
| | - Michael V Tirabassi
- Department of Surgery, UMass Medical School - Baystate, Springfield, MA; Baystate Children's Hospital, Springfield, MA
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Patel NJ, Dultz L, Ladhani HA, Cullinane DC, Klein E, McNickle AG, Bugaev N, Fraser DR, Kartiko S, Dodgion C, Pappas PA, Kim D, Cantrell S, Como JJ, Kasotakis G. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2021; 221:873-884. [DOI: 10.1016/j.amjsurg.2020.11.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/06/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
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Bui JT, Browder SE, Wilson HK, Kindell DG, Ra JH, Haithcock BE, Long JM. Does routine uniportal thoracoscopy during rib fixation identify more injuries and impact outcomes? J Thorac Dis 2020; 12:5281-5288. [PMID: 33209362 PMCID: PMC7656410 DOI: 10.21037/jtd-20-2087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Flail chest and severely displaced rib fractures due to blunt trauma can be associated with intrathoracic injuries. At our institution, two thoracic surgeons perform all surgical stabilization of rib fractures (SSRF): one performs routine uniportal thoracoscopy (R-VATS) at the time of SSRF and the other for only select cases (S-VATS). In this pilot study, we hypothesized that R-VATS at the time of SSRF identifies and addresses intrathoracic injuries not seen on imaging and may impact patient outcomes. Methods A retrospective review of all patients who underwent SSRF from 2013–2019 at our institution was performed for severely displaced rib fractures or flail chest. Data collected included demographics, imaging results, treatment strategy, and operative findings. Results Ninety-nine patients underwent SSRF. Uniportal thoracoscopy was performed on 69% of these patients. When thoracoscopy was performed, 31 additional injuries were identified. R-VATS identified 23 additional intrathoracic findings at time of thoracoscopy not seen on CT scan compared to 8 findings in the S-VATS group (P=0.367). At 3 months follow-up, one empyema and one diaphragmatic hernia required reoperation—neither of which underwent thoracoscopy at time of SSRF. There were no differences in LOS, operative times, and overall mortality between the SSRF/thoracoscopy and SSRF only groups. Conclusions R-VATS at the time of SSRF did not identify a statistically significant greater number of occult intrathoracic injuries compared to S-VATS. R-VATS was not associated with increased operative time, LOS, and mortality. Further study is needed to determine if there is benefit to R-VATS in patients meeting requirements for rib fracture repair.
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Affiliation(s)
- Jenny T Bui
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sydney E Browder
- Department of Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Hadley K Wilson
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Daniel G Kindell
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Jin H Ra
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Surgery, Division of Trauma Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Benjamin E Haithcock
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Jason M Long
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina Hospitals, Chapel Hill, NC, USA
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Wu TH, Lin HL, Chou YP, Huang FD, Huang WY, Tarng YW. Facilitating ventilator weaning through rib fixation combined with video-assisted thoracoscopic surgery in severe blunt chest injury with acute respiratory failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:49. [PMID: 32050985 PMCID: PMC7017455 DOI: 10.1186/s13054-020-2755-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 01/29/2020] [Indexed: 12/04/2022]
Abstract
Background Severe blunt chest injury sometimes induces acute respiratory failure (ARF), requiring ventilator use. We aimed to evaluate the effect of performing rib fixation with the addition of video-assisted thoracoscopic surgery (VATS) on patients with ARF caused by blunt thoracic injury with ventilator dependence. Methods This observational study prospectively enrolled patients with multiple bicortical rib fractures with hemothorax caused by severe blunt chest trauma. All patients received positive pressure mechanical ventilation within 24 h after trauma because of ARF. Some patients who received rib fixation with VATS were enrolled as group 1, and the others who received only VATS were designated as group 2. The length of ventilator use was the primary clinical outcome. Rates of pneumonia and length of hospital stay constituted secondary outcomes. Results A total of 61 patients were included in this study. The basic demographic characteristics between the two groups exhibited no statistical differences. All patients received operations within 6 days after trauma. The length of ventilator use was shorter in group 1 (3.19 ± 3.37 days vs. 8.05 ± 8.23, P = 0.002). The rate of pneumonia was higher in group 2 (38.1% vs. 75.0%, P = 0.005). The length of hospital stay was much shorter in group 1 (17.76 ± 8.38 days vs. 24.13 ± 9.80, P = 0.011). Conclusion Rib fixation combined with VATS could shorten the length of ventilator use and reduce the pneumonia rate in patients with severe chest blunt injury with ARF. Therefore, this operation could shorten the overall length of hospital stay.
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Affiliation(s)
- Tung-Ho Wu
- Department of Critical Care Medicine, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan.,Division of Thoracic Surgery, Department of Surgery, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsing-Lin Lin
- Department of Critical Care Medicine, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Yi-Pin Chou
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan.,Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan.,Department of Cosmetic Science, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Fong-Dee Huang
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Yen Huang
- School of Accounting and Finance, Beijing Institute of Technology, Zhuhai, China
| | - Yih-Wen Tarng
- Department of Orthopedics, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung City, 813, Taiwan.
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Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
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Ziapour B, Mostafidi E, Sadeghi-Bazargani H, Kabir A, Okereke I. Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis). Eur J Trauma Emerg Surg 2019; 46:337-346. [PMID: 31848631 DOI: 10.1007/s00068-019-01275-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE In this systematic review, we analyzed the optimal time range to evacuate traumatic-retained hemothorax using video-assisted thoracoscopic surgery (VATS). METHODS We searched PubMed, EMBASE, the Cochrane Register of Controlled Trials, Google Scholar, and the U.S. National Library of Medicine clinical trials database up to February 2019. Randomized controlled trials (RCTs) and observational studies with relevant data were included. Data were extracted from studies that reported the success, mortality, or length of hospital stay (LOS) after using VATS during at least two out of three of our time-ranges of interest: days 1-3 (group A), days 4-6 (group B), and day 7 or later (group C). RESULTS Six cohort studies with 476 total participants were included in the meta-analysis. The patients in group A had a significantly higher success rate than those in group C (RR = 0.42; 95% CI = 0.21-0.84, p = 0.01). The total LOS for patients whose retained hemothorax was evacuated in group A was 4.7 days shorter than that for those in group B (95% CI = - 5.6 to - 3.8, p = 0.006). Likewise, group B patients were discharged 18.1 days earlier than group C patients (95% CI = - 22.3 to - 14, p < 0.001). Short-term mortality was not decreased by early VATS. CONCLUSIONS Our results indicate that VATS should be considered within the first three days of admission if this intervention is the clinician's choice to evacuate a traumatic-retained hemothorax. Protocol registration number in PROSPERO: CRD42017046856.
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Affiliation(s)
- Behrad Ziapour
- Tufts Medical Center, 800 Washington Street #1035, Boston, MA, 02111, USA.
| | | | - Homayoun Sadeghi-Bazargani
- Department of Statistics and Epidemiology, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ikenna Okereke
- Chief of Thoracic Surgery, Division of Cardiovascular and Thoracic Surgery, Program Director, Cardiothoracic Fellowship Program, Division of Cardiothoracic Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555-0528, USA
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Shi J, Wang Y, Geng W. Thoracoscope and thoracotomy in the treatment of thoracic trauma. Pak J Med Sci 2019; 35:1238-1242. [PMID: 31488985 PMCID: PMC6717472 DOI: 10.12669/pjms.35.5.514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare clinical effects of thoracoscopic surgery and thoracotomy in the treatment of thoracic trauma. Methods: Two hundred and fourteen patients with thoracic trauma were randomly divided into a control group and an observation group, 107 in each group. The control group was treated with conventional thoracotomy, while the observation group was treated with thoracoscopic surgery. The operation-related indications, hospitalization, postoperative complications and inflammatory factor level were observed and compared between the two groups. The study was conducted from April 2016 to February 2018. Results: The duration of operation of the observation group was shorter than that of the control group, the amount of bleeding during operation of the observation group was less than that of the control group, and the postoperative visual analogue score (VAS) of the observation group was lower than that of the control group; the difference were statistically significant (P<0.05). The hospitalization time, time of off-bed activity and time of resuming daily life of the observation group were shorter than those of the control group, and the amount of drainage fluid of the observation group within 24 hours after operation was less than that of the control group; the differences had statistical significance (P<0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P>0.05). The levels of C-reactive protein (CRP), tumor necrosis factor (TNF)-a and interleukin (IL)-6 in both groups after surgery were higher than those before surgery, but the indicators in the observation group were lower than those in the control group (P<0.05). Conclusion: Thoracoscopic surgery can reduce pains of patients, speed up recovery, and reduce incidence of surgical infection in the treatment of thoracic trauma. It is a safe and effective treatment method, which is worth clinical application.
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Affiliation(s)
- Juan Shi
- Juan Shi, Department of Cardiothoracic Surgery, Binzhou People's Hospital, Shandong, 256610, China
| | - Yucun Wang
- Yucun Wang, Department of Rheumatology and Immunology, Binzhou People's Hospital, Shandong, 256610, China
| | - Wenzhen Geng
- Wenzhen Geng, Department of Cardiovascular Medicine, Binzhou People's Hospital, Shandong, 256610, China
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