Thoracoscopy for the acutely injured patient

Could video-assisted thoracoscopic surgery be feasible for blunt trauma patients with massive haemothorax?

INTRODUCTION

The study reviewed the experience of video-assisted thoracoscopic surgery (VATS) for the treatment of massive haemothorax (MHT).

MATERIALS AND METHODS

All adult patients who sustained blunt trauma with a diagnosis of traumatic haemothorax or pneumothorax (ICD9 860; ICD10 S27.0-2), injury to the heart and lungs (ICD9 861; ICD10 S26, S27.3-9), and injury to the blood vessels of the thorax (ICD9 901; ICD10 S25) were queried from the trauma registry between 2014 and 2018. Patients who had chest tube drainage amounts meeting the criteria for MHT and who underwent subsequent operations were eligible for analyses. The patients were divided into VATS or thoracotomy groups based on the surgical modalities. Descriptions and analyses of the two groups were made.

RESULTS

Thirty-eight patients were enroled in the study, including 8 females (21%) and 30 males. The median age was 47.0 (first quartile (Q1) 25.5 and third quartile (Q3) 59.3) years. Twenty-three patients were in the VATS group, six (26%) of whom were converted to thoracotomy. There were no obvious differences in age, sex, pulse rate, or systolic pressure on arrival to the ED or after resuscitation between the two groups. The laboratory data were worse amongst the thoracotomy group, especially the arterial blood gas analysis (ABG) results: pH 7.2 (7.1, 7.3) vs. 7.4 (7.2, 7.4); HCO₃ 14.6 (12.4, 18.7) vs. 19.7 (16.1, 23.9) mEq/L; base excess (BE) -12.6 (-15.8, -7.8) vs. -5.2 (-11.1, -0.9) mEq/L. The PaO₂/FiO₂ ratio was lower in the thoracotomy group (91.4 (68.5, 193.3) vs. 245.3 (95.7, 398.0) mmHg). The thoracotomy group had coagulopathy (INR 1.6 (1.2, 1.9) vs. 1.3 (1.1, 1.4)) and required more blood transfusions (WB and PRBC 36.0 (16.0, 48.0) vs. 12.0 (4.0, 24.0) units; FFP 20.0 (6.0, 50.0) vs. 6.0 (2.0, 20.0) unit). No factors associated with VATS conversion to thoracotomy could be identified.

CONCLUSIONS

VATS could be applied to selected blunt trauma patients with MHT. The major differences between the VATS and thoracotomy groups were coagulopathy, acidosis, PaO₂/FiO₂ ratio < 200 mmHg, or a persistent need for blood transfusion.

Early Management of Retained Hemothorax in Blunt Head and Chest Trauma

Background

Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3–4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries.

Materials and methods

From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation.

Result

All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were discharged (11.74 vs. 14.10, p < 0.05).

Discussion

In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma.

Thoracostomy tube function not trajectory dictates reintervention

BACKGROUND

Hemothorax and/or pneumothorax can be managed successfully managed with tube thoracostomy (TT) in the majority of cases. Improperly placed tubes are common with rates near 30%. This study aimed to determine whether TT trajectory affects the rate of secondary intervention.

METHODS

A retrospective review of all adult trauma patients undergoing TT placement over a 4-y period was performed. TT trajectory was classified as ideal, nonideal, or kinked-based on anterior-posterior chest x-ray. TTs with sentinel port outside the thoracic cavity were excluded. The primary outcome was any secondary intervention.

RESULTS

Four-hundred eighty-six patients and a total of 547 hemithoraces underwent placement and met inclusion criteria. The majority of patients were male (76%), with a median age of 41 y, and majority suffered blunt trauma ideal trajectory was identified in 429 (78.4%). Kinked TTs were noted in 33 (6%) hemothoraces with a 45.5% replacement rate. Review with staff demonstrates inherent bias to replace kinked TTs. The overall secondary intervention rate was 27.8%. Kinked TTs were removed from final analysis due to treatment bias. Subsequent analysis demonstrated no significant difference between ideal and nonideal trajectories (25.1% versus 34.1%, P = 0.09).

CONCLUSIONS

Intrathoracic trajectory of nonkinked TTs with the sentinel port within the thoracic cavity does not affect secondary intervention rates, including the rate of surgical intervention.

The surgical stabilization of multiple rib fractures using titanium elastic nail in blunt chest trauma with acute respiratory failure

BACKGROUND

Blunt chest injuries are usually combined with multiple rib fractures and severe lung contusions. This can occasionally induce acute respiratory failure and prolong ventilations. In order to reduce the periods of ventilator dependency, we propose a less invasive method of fixing multiple rib fractures.

METHODS

Since October 2009, we have developed a new method to fix fractured ribs caused by blunt trauma. Rib fixations were performed using 2.0- or 2.5-mm intramedullary titanium elastic nails (TEN), with the help of video-assisted thoracoscopic surgery (VATS) and minimal thoracic incisions. All the patients' demographics and postoperative data were collected.

RESULTS

From January 2010 to December 2012, a total of 65 patients presenting with multiple rib fractures resulting in acute respiratory failure were included in the study. Twelve patients received the new surgical fixation. Rib fixations were performed at an average of 4 days after trauma. Patients were successfully weaned off ventilators after an average of 3 days. The average length of stay in the hospital and the intensive care unit (ICU) was shorter for the patients with fixation than for nonsurgical patients. All twelve patients returned to normal daily activities and work.

CONCLUSIONS

In the reconstruction of an injured chest wall, the VATS with TENs fixation in multiple rib fractures is feasible. This method is also effective in decreasing the length of the surgical wound. Because the structure of the chest cage is protected, the period of mechanical ventilation is shortened and the length of stay in the hospital and the ICU can be reduced.

How early should VATS be performed for retained haemothorax in blunt chest trauma?

BACKGROUND

Blunt chest injury is not uncommon in trauma patients. Haemothorax and pneumothorax may occur in these patients, and some of them will develop retained pleural collections. Video-assisted thoracoscopic surgery (VATS) has become an appropriate method for treating these complications, but the optimal timing for performing the surgery and its effects on outcome are not clearly understood.

MATERIALS AND METHODS

In this study, a total of 136 patients who received VATS for the management of retained haemothorax from January 2003 to December 2011 were retrospectively enrolled. All patients had blunt chest injuries and 90% had associated injuries in more than two sites. The time from trauma to operation was recorded and the patients were divided into three groups: 2-3 days (Group 1), 4-6 days (Group 2), and 7 or more days (Group 3). Clinical outcomes such as the length of stay (LOS) at the hospital and intensive care unit (ICU), and duration of ventilator and chest tube use were all recorded and compared between groups.

RESULTS

The mean duration from trauma to operation was 5.9 days. All demographic characteristics showed no statistical differences between groups. Compared with other groups, Group 3 had higher rates of positive microbial cultures in pleural collections and sputum, longer duration of chest tube insertion and ventilator use. Lengths of hospital and ICU stay in Groups 1 and 2 showed no statistical difference, but were longer in Group 3. The frequency of repeated VATS was lower in Group 1 but without statistically significant difference.

DISCUSSION

This study indicated that an early VATS intervention would decrease chest infection. It also reduced the duration of ventilator dependency. The clinical outcomes were significantly better for patients receiving VATS within 3 days under intensive care. In this study, we suggested that VATS might be delayed by associated injuries, but should not exceed 6 days after trauma.

The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma

OBJECTIVES

Retained haemothorax and pneumothorax are the most common complications after blunt chest traumas. Lung lacerations derived from fractures of the ribs are usually found in these patients. Video-assisted thoracoscopic surgery (VATS) is usually used as a routine procedure in the treatment of retained pleural collections. The objective of this study was to find out if there is any advantage in adding the procedure for repairing lacerated lungs during VATS.

METHODS

Patients who were brought to our hospital with blunt chest trauma were enrolled into this prospective cohort study from January 2004 to December 2011. All enrolled patients had rib fractures with type III lung lacerations diagnosed by CT scans. They sustained retained pleural collections and surgical drainage was indicated. On one group, only evacuation procedure by VATS was performed. On the other group, not only evacuations but also repair of lung injuries were performed. Patients with penetrating injury or blunt injury with massive bleeding, that required emergency thoracotomy, were excluded from the study, in addition to those with cardiovascular or oesophageal injuries.

RESULTS

During the study period, 88 patients who underwent thoracoscopy were enrolled. Among them, 43 patients undergoing the simple thoracoscopic evacuation method were stratified into Group 1. The remaining 45 patients who underwent thoracoscopic evacuation combined with resection of lung lacerations were stratified into Group 2. The rates of post-traumatic infection were higher in Group 1. The durations of chest-tube drainage and ventilator usage were shorter in Group 2, as were the lengths of patient intensive care unit stay and hospital stay.

CONCLUSIONS

When compared with simple thoracoscopic evacuation methods, repair and resection of the injured lungs combined may result in better clinical outcomes in patients who sustained blunt chest injuries.

Thoracoscopy for Trauma

Thoracoscopy has numerous applications for both diagnosis and treatment in thoracic trauma. It is excellent for the diagnosis of diaphragmatic injuries, mediastinal evaluation, and the assessment of persistent air-leak. It offers therapeutic intervention for diaphragmatic lacerations, thoracic bleeding in stable patients, evacuation of residual hemothorax, air-leaks, and the prevention and treatment of empyema. Judiciously applied, it is a powerful tool in the armamentarium of the trauma surgeon.

Anesthetic management of thoracic trauma

PURPOSE OF REVIEW

Trauma remains a leading cause of death across all age groups. Thoracic injury is a contributing cause in approximately half of these. Despite being potentially life threatening, most thoracic trauma is managed nonoperatively or with an intercostal catheter. Only 10% of thoracic trauma patients will require emergency thoracotomy. Many more will undergo emergency or urgent surgical intervention for coexisting injuries. Thoracic injuries are dynamic. It is crucial for the anesthesiologist to continually reassess the patient, so that the manifestations of evolving injuries may be detected as early as possible and appropriate management decisions made. Up-to-date knowledge of injury patterns, mechanisms, pathophysiology, and operative and nonoperative management will facilitate optimal management of these patients.

RECENT FINDINGS

There is recent literature discussing the surgical, anesthetic and critical care management of a range of thoracic injuries resulting from either blunt or penetrating trauma.

SUMMARY

Initial resuscitation and surgical management of patients with thoracic trauma continue to evolve. Improvements in prehospital care and diagnostic techniques as well as development of minimally invasive interventions mean that the anesthesiologist may be required to provide care to unstable patients in an expanded range of scenarios and environments.

Removal of an impaled knife under thoracoscopic guidance

Thoracoscopy is being increasingly utilized in stable patients to manage both blunt and penetrating injuries. The case of a patient who presented with a knife impaled in the chest is reported. The knife was able to be removed under thoracoscopic guidance, avoiding thoracotomy.

[Current issues in the diagnosis and treatment of penetrating chest trauma]

INTRODUCTION

Successful treatment of penetrating chest trauma largely depends on the accurate and rapid diagnostic work-up, as well as the adequate surgical management. The authors discuss current issues in the diagnosis and the treatment of penetrating chest injuries based on the analysis of 109 cases.

PATIENTS AND METHODS

82 men and 27 women with penetrating chest trauma were studied. The average age of the patients was 37.8 years. The injury was caused by stabbing in 104 cases (95.4%), gunshot in 4 patients (3.7%) and explosion in one case (0.9%). 41 patients had cardiac and pericardial injuries. In those, 19 (46.3%) patients had a chest X-ray, echocardiography was done in nine cases (22%), while CT scan and diagnostic VATS were performed in two patients, respectively. All patients underwent surgery except one, who was treated conservatively.In all of the 68 patients, who had no cardiac injuries, a chest X-ray was performed. Echocardiography was done in six (8.8%) cases, diagnostic VATS in four (5.9%) patients, and abdominal ultrasound scan in 3 (4.4%) cases. Chest tube was inserted in 13 patients (19.1%), an open surgery was performed in 51 cases, while in 4 cases VATS was carried out.

RESULTS

In the group of patients with cardiac and pericardial injuries, the sensitivity of the chest X-ray, echocardiography and VATS were 57.9%, 88.9% and 100%, respectively. Further, specificity of the above were 26.3%, 88.9% and 100%, respectively. However, in patients with non-cardiac injuries, the sensitivity of the chest X-ray was 100%, and both the specificity and sensitivity of VATS was 100%. Postoperative complication rate was 12.6% overall (15% in cases with cardiac injury and 10.9% in the non-cardiac subgroup). Mortality rate was 7.3% among the patients with cardiac injury, while there was no mortality detected in the non-cardiac subgroup. The average mortality rate was 2.8%.

CONCLUSION

Patients with penetrating chest trauma should undergo a rapid and accurate diagnostic work-up followed by an adequate surgical management in order to keep their prognosis relatively good.

[The role of VATS in the treatment of blunt thoracic injuries]

AIMS

Video assisted thoracoscopy (VATS) is a more and more frequently used method in the diagnosis and treatment of blunt thoracic trauma. In some cases it has diagnostic and in others therapeutic effect. The authors analyze the role of VATS in the diagnosis and the treatment of 83 patients treated with haemothorax.

PATIENTS AND METHODS

There were 83 patients treated (60 male, 23 female, mean age of 54.4 years) with haemothorax caused by blunt thoracic trauma. Chest tube drainage was used in 31 (37.3%) cases. Urgent thoracotomy was performed in only two (2.4%) cases. Elective, planned VATS was used in 11 (13.3) cases. All of these 3 were diagnostic and 8 were therapeutic procedures. In three cases rupture of the diaphragm was diagnosed with the use of VATS which were treated through thoracotomy. In the remaining 8 cases haematoma evacuation and in 3 cases intercostal artery bleeding were treated with VATS.

RESULTS

No complications related to the procedure were observed. The thoracotomy in all 3 cases verified the diaphragmatic injuries. The 8 patients undergone therapeutic VATS recovered. The mean hospital stay after VATS was 7.8 days and 11.3 days after thoracotomy in the patients with diaphragmatic injury.

CONCLUSIONS

The VATS has a significant role in the diagnosis of blunt thoracic, especially of diaphragmatic, injuries. In other cases the VATS has good therapeutic effect.

Role of thoracoscopy in acute management of chest injury

PURPOSE OF REVIEW

To review the literature on the use of video-assisted thoracoscopic surgery for the diagnosis and treatment of intrathoracic injuries.

RECENT FINDINGS

Video-assisted thoracoscopic surgery is a relatively recent innovation. It was originally promoted for the treatment of retained hemothorax and the diagnosis of diaphragm injury. It is highly effective for the management of those problems. Recent studies have focused on video-assisted thoracoscopic surgery for treatment of chest wall bleeding, diagnosis of transmediastinal injuries, pericardial window and persistent pneumothorax. In properly selected patients, video-assisted thoracoscopic surgery is extremely efficacious in managing these problems.

SUMMARY

The role of video-assisted thoracoscopic surgery in the management of acute chest injury is expanding. It is an invaluable tool for the trauma surgeon.

Video-Assisted Thoracoscopic Surgery in the Treatment of Chest Trauma: Long-Term Benefit

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has gained an increasing importance as a diagnostic and therapeutic tool in chest trauma. Several studies have demonstrated its feasibility and safety, but only a few addressed the long-term benefit of VATS. The aim of this study was to evaluate the short-term and long-term benefits of VATS in chest trauma, with emphasis on the patient's point of view.

METHODS

Medical records of patients with chest trauma during a 10-year period were reviewed. The study included 77 patients (37 patients in the VATS group and 40 in the thoracotomy group). Forty-four patients who underwent operative treatment during the study period were excluded from the study. Hospital charts and a telephone questionnaire were used to evaluate the outcome.

RESULTS

No deaths occurred in either group. Clotted hemothorax was the most common finding. The incidence of wound and pulmonary complication were higher in the thoracotomy group. Patients in the thoracotomy group needed significantly higher doses of narcotic analgesia. Average time to resume normal activity was shorter in the VATS group. More than 2 years after discharge, the rate of return to a normal lifestyle was 81% in the VATS group and 60% of the thoracotomy group. Patients in the VATS group were generally more satisfied with their health status and surgical scars.

CONCLUSIONS

The results of this study show that for stable patients with chest trauma, video assisted thoracic surgery is feasible and safe. Moreover, it is tolerated better than open thoracotomy, has a favorable postoperative course, a superior long-term outcome, and greater patient satisfaction.

Video-Assisted Thoracic Surgical Applications in Thoracic Trauma

VATS is a valuable and safe way to manage many problems in thoracic trauma. It may allow earlier diagnosis and treatment of posttraumatic complications of chest injuries with less morbidity. This approach has already demonstrated advantages in such entities as retained hemothorax. The reduced pain and morbidity are attractive features compared with open thoracotomy. VATS continues to evolve in thoracic trauma, but unquestionably has proved value.