A prospective evaluation of thoracoscopy for the diagnosis of penetrating thoracoabdominal trauma

Awake Emergency Department Thoracoscopic Investigation of Penetrating Diaphragmatic Injuries: A Novel Minimally Invasive Technique of Diagnosis

Background: The diagnosis of occult penetrating diaphragmatic trauma remains challenging, with conventional imaging offering inadequate accuracy for diagnosis. Minimally invasive surgical options for evaluating the diaphragm conventionally require general anesthesia. We propose a technique for evaluating the diaphragm via awake thoracoscopy in the emergency department. Methods: A prospective interventional study was conducted to investigate the safety and accuracy of emergency department awake thoracoscopy for diagnosing diaphragmatic injuries in penetrating thoracoabdominal trauma. All adult patients who presented to the trauma unit with penetrating thoracoabdominal trauma who were hemodynamically stable were enrolled. The patients underwent emergency department awake thoracoscopy with a rigid endoscope through a previously inserted intercostal drain. Only local anesthesia and conscious sedation were provided. Results: Forty patients were enrolled. All 40 (100%) were men, and the median age was 34 years. Thirty-four had stab wounds (85%), 5 had gunshot wounds (12.5%), and 1 had a suspected iatrogenic diaphragm injury during intercostal drain insertion (2.5%). In 32 (80%), the diaphragm was well visualized, of whom 7 (17.5%) had diaphragm injuries. In the remaining 8 patients in whom the diaphragm was not well visualized, only 1 (2.5%) had a diaphragmatic injury. The diaphragmatic injuries that were identified were confirmed and repaired during a subsequent explorative laparoscopy. There were no procedure-related complications in any of the patients during short-term follow-up. Conclusions: Awake thoracoscopy is safe, feasible, and accurate for the diagnosis of occult diaphragm injuries and may offer a modality for assessment that does not require general anesthesia.

Selective nonoperative management of penetrating abdominal trauma at a level 1 Canadian trauma centre: a quest for perfection

Background

Many patients who sustain penetrating abdominal trauma can be managed nonoperatively. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines on selective nonoperative management (SNOM), and this approach is well established. The purpose of this study is to assess the management of penetrating abdominal trauma, including the selection of patients for SNOM and the use of this approach, at a Canadian level 1 trauma centre.

Methods

We used the Hamilton Health Sciences trauma registry to compile data on patients aged 16 years and older who sustained penetrating abdominal trauma from Jan. 1, 2011, to Dec. 31, 2017. Hemodynamically stable, nonperitonitic patients without evisceration or impalement were considered potentially eligible for SNOM. We compared the SNOM group of patients with the immediate operative (IOR) group. Our primary outcome was SNOM failure; secondary outcomes included length of stay, repeat imaging, computed tomography (CT) protocol, laparoscopy in left thoracoabdominal trauma, and nontherapeutic and negative laparotomies.

Results

We included 191 patients with penetrating abdominal trauma; 123 underwent SNOM and 68 underwent IOR. Of the 68 patients in the IOR group, 4 underwent nontherapeutic laparotomies. Of the 123 patients in the SNOM group, this approach failed in 7 (5.7%). Patients who were successfully managed with SNOM had an average length of stay of 25.4 hours (7.9–43.0 h), with no repeat imaging in 34/35 (97.1%). Only 5 of the 47 patients with flank/back wounds had a CT scan that included luminal contrast. Only 3 of the 58 patients with left thoracoabdominal wounds underwent same-admission laparoscopy, all demonstrating diaphragmatic defects.

Conclusion

Our study demonstrates a high rate of compliance with the EAST SNOM guidelines, including minimal failure rate of SNOM and an efficient use of resources as demonstrated by reduced length of stay and minimal use of reimaging. We identified 2 opportunities for improvement: improved use of luminal contrast CT in patients with flank/back wounds and improved use of diagnostic laparoscopy in patients with left thoracoabdominal wounds.

Contribution of videothoracoscopy in the management of thoracic wounds with diaphragmatic lesions: A single African center experience

Background and aims

The management of thoracic wounds induced by sharp objects outside an extreme emergency remains controversial. The means vary from exploratory thoracotomy to simple monitoring. Between these two extremes, videothoracoscopy as a means of exploration plays an important role and helps to avoid unnecessary thoracotomies, thus making it possible to make early diagnosis of diaphragmatic lesions. The aim of this study was to report our experience in videothoracoscopic management of thoracic wounds by penetrating objects.

Material and methods

From January 2010 to December 2015, 58 patients with an average age 22.5 years with a thoracic stab wound with a stable hemodynamic condition underwent videothoracoscopy.

Results

Thoracoscopy revealed a diaphragmatic injury in 17 patients, cardiac or pericardial wounds in four and a haemorrhagic pulmonary injury in 1; all were treated at video-assisted mini-thoracotomy. In the other 36 patients, videothoracoscopic exploration did not demonstrate any intra-thoracic lesion and the procedure consisted of aspiration of a residual hemothorax with the installation of a good view-controlled thoracic drainage. Hospital stay was between 48 and 72 h.

Conclusion

Videothoracoscopy is a safe and effective way to explore the thoracic cavity in patients with chest wounds with suspected diaphragmatic lesions. It avoids thoracotomy especially in hemodynamically stable patients.

Evaluation of Thoracoscopy with Single-Lumen Endotracheal Tube Intubation and Laparoscopy in the Diagnosis of Occult Diaphragmatic Injuries in Penetrating Thoracoabdominal Trauma

Background: The diagnosis of traumatic diaphragmatic injuries (TDIs) after penetrating thoracoabdominal trauma is challenging and conventional imaging is unreliable. Laparoscopy and thoracoscopy are minimally invasive modalities of choice in the diagnosis and management of TDI. A little is known on the value of thoracoscopy with single-lumen endotracheal tube intubation (SLETI) in the diagnosis of occult diaphragmatic injuries, and how it compares with laparoscopy. Methods: A prospective study evaluated thoracoscopy with SLETI as a diagnostic tool for occult TDI. Thoracoscopy was followed by diagnostic laparoscopy to confirm the findings and manage diaphragmatic and intra-abdominal injuries. Results: Thirty-one patients underwent thoracoscopy followed by laparoscopy. Majority were men (n = 27, 87%). The median age was 30 years. Twenty-six patients had stab wounds (83.8%), and 5 had gunshot wounds (16.1%). The incidence of diaphragmatic injury was 42% (n = 13). Thoracoscopy with SLETI correctly identified 12 (92%) patients with diaphragmatic injury, but 1 patient had dense pleural adhesions. Diagnostic laparoscopy identified all injuries. Conclusion: Thoracoscopy with SLETI and laparoscopy are feasible, safe, and accurate approaches in detecting TDI in stable patients with penetrating thoracoabdominal injuries. However, dense pleural adhesions may prevent thoracoscopy. Laparoscopy allows inspection of both hemidiaphragms and diagnoses associated intra-abdominal injuries. The choice of primary technique will depend on the individual clinical scenario.

Traumatic Diaphragmatic Injury: A Marker of Serious Injury Challenging Trauma Surgeons

The objectives of this study are (1) to evaluate prevalence of traumatic diaphragmatic injury (TDI), (2) identify the predictors of mortality, and (3) study the accuracy of investigations in survivors of TDI. Retrospective analysis of prospectively maintained database of TDI from January 2007 to December 2011. Emergency department (ED) records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the SPSS ver.15 software. TDI was identified in 75 individuals. Thirty-two of 75 (42.6 %) cases were brought dead to the hospital, and 43/75 (57.3 %) were survivors presented to emergency department, diagnosed to have TDI intraoperatively. Seven of 43 (16.3 %) died postoperatively. Mortality in TDI was significantly related to age (p = 0.001), injury severity (p < 0.001), site of TDI (p = 0.002), and associated injuries (p = 0.021, odds ratio of 9). Death increased with increase in the number of organ injured (p < 0.001, odds ratio of 12). Multi-detector computer tomography (MDCT) detected TDI in 23/26 (88.5 %) cases preoperatively. Laparotomy (p < 0.001, odds ratio of 22) and thoracotomy (p = 0.021, with odds ratio of 9) were associated with survival benefit when compared to minimal invasive surgery in injured cases. The prevalence of TDI was 2.67 %, TDI's mark severity of injury. Mortality increases with increasing number of organ injured. Right-sided or bilateral injury of diaphragm is associated with increased mortality.

Management guidelines for penetrating abdominal trauma

PURPOSE OF REVIEW

Patients with penetrating abdominal trauma are at risk of harboring life-threatening injuries. Many patients are in need of emergent operative intervention. However, there are clearly patients who can be safely managed nonoperatively. This review evaluates the literature to identify management guidelines for patients with penetrating abdominal trauma.

RECENT FINDINGS

Accumulating evidence supports nonoperative management of patients with stab wounds to the thoracoabdominal region, the back, flank, and anterior abdomen. Furthermore, select patients with gunshot wounds can be safely managed nonoperatively.

SUMMARY

Shock, evisceration, and peritonitis warrant immediate laparotomy following penetrating abdominal trauma. Thoracoabdominal stab wounds should be further evaluated with chest X-ray, ultrasonography, and laparoscopy or thoracoscopy. Wounds to the back and flank should be imaged with CT scanning. Anterior abdominal stab wound victims can be followed with serial clinical assessments. The majority of patients with gunshot wounds are best served by laparotomy; however, select patients may be managed expectantly.

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review

PURPOSE

Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS.

METHODS

A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs.

RESULTS

There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS.

CONCLUSION

Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Laparoscopic management of left thoracoabdominal stab wounds: a prospective study

BACKGROUND

Left thoracoabdominal stab wounds (LTSWs) leading to diaphragmatic injuries can cause serious morbidity and mortality. The diagnosis and treatment of LTSWs are controversial. This study investigated the reliability of laparoscopy for the diagnosis and treatment of diaphragmatic lacerations in hemodynamically stable patients with an LTSW, hypothesizing that laparoscopy is sufficient for diagnosing and treating diaphragmatic injury after an LTSW.

METHODS

This study included 36 cases of LTSWs with no hemodynamic instability or abdominal tenderness seen between June 2002 and June 2007. After systemic examination and resuscitation of the patients, chest x-ray and focused assessment with sonography for trauma were carried out and then laparoscopic exploration was performed in all cases.

RESULTS

Of the 36 cases, 36.1% (n=13) had injuries to the diaphragm and 53.8% (7/13) had associated intraabdominal injuries. Nine (69.2%) of the patients with diaphragmatic injuries, but no hollow organ injuries, were repaired through laparoscopy. The hemopneumothorax was found in 33.3% (n=12) of the patients. No relationship was seen between diaphragmatic injuries and the location of the LTSW and existence of hemopneumothorax.

CONCLUSIONS

Laparotomy was required in only 11.1% (4/36) of the cases with LTSWs and 30.8% (4/13) of the cases with diaphragmatic injury. Diagnostic and therapeutic laparoscopy was a sufficient and necessary surgical procedure in cases with a hemodynamically stable LTSW, when emergency surgery (laparotomy or thoracotomy) was not necessary.

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.

Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile

INTRODUCTION

While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent.

PATIENTS AND METHODS

We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury.

RESULTS

Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis.

CONCLUSION

Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.

Best timing for thoracoscopic evacuation of retained post-traumatic hemothorax

OBJECTIVE

To determine the best timing for thoracoscopic drainage of clotted hemothorax in order to ensure safe and effective results and to identify risk factors associated with drainage failure.

MATERIALS AND METHODS

Cohort retrospective study of 139 consecutive patients who underwent thoracoscopic retained hemothorax drainage between April 1997 and May 2005.

RESULTS

The procedure was successful in 102 patients (73.4%), in whom complete evacuation was achieved, with no accumulation of fluid in the pleural cavity requiring reintervention. Conversion to thoracotomy was required in 22 patients (15.8%) because of the inability to attain adequate drainage of clots and collections and lung re-expansion. Fifteen patients (10.8%) required reintervention as a result of fluid accumulation in the pleural cavity and lung collapse, and thoracotomy was performed in all those cases. The best results were obtained when thoracoscopic drainage was performed before the fifth day. There were 33 major post-operative complications including 20 cases of empyema of which 10 required thoracotomy, and 13 bronchopleural leaks, four of which required open surgery. There were no fatal outcomes in the study group.

CONCLUSIONS

Videothoracoscopy must be considered the procedure of choice for the treatment of retained post-traumatic hemothorax. It is a safe and effective procedure allowing the successful treatment of up to 73.4% of patients. Best results are obtained when drainage is performed within the first five days after trauma.

[The value of thoracoscopy in thorax trauma]

A hemodynamically stable patient presenting with persistent bleeding through his chest tube (ICD) is a classic indication for early thoracoscopic intervention in trauma. The source of bleeding and air leaks can be identified and often treated: bleeding and perforated pulmonary segments can be resected, and chest wall bleeding may be coagulated or sutured. Injuries to the diaphragm are difficult to diagnose, as they might not be seen in conventional trauma imaging without gross herniation of intra-abdominal contents into the thoracic cavity. Identifying the site of diaphragm perforation can give useful hints in thoracoabdominal trauma, identifying injured cavities and localizing the bullet or stab tract. Most often, diaphragmatic defects may be closed during diagnostic thoracoscopy as well. Non- or partially drainable hemothorax is another indication for thoracoscopy. Coagulated blood can be mechanically mobilised, and aspirated or primary bleeding may be stopped. Effective lavage and a high-performance suction device are required. Correct placement of the drainage is part of optimized therapy, along with inspection of all intrathoracic organs and surfaces. Furthermore, surgical and anaesthesiological teamwork and experience are prerequisites for the fast, professional application of a minimally invasive thoracoscopic approach in chest trauma patients. Diagnostically and theurapeutically, thoracoscopy plays an important role in the trauma setting--in the case of hemodynamically stable patients.

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.

Incidência de empiema pleural nos ferimentos tóraco-abdominais

OBJETIVO: Os ferimentos penetrantes com comprometimento simultâneo das cavidades torácica e abdominal (FTA), além da dificuldade diagnóstica, merecem especial atenção em relação à conduta adotada para o tratamento do espaço pleural. O objetivo do presente estudo foi identificar os principais fatores relacionados à incidência de empiema pleural em pacientes com ferimentos penetrantes localizados na transição toracoabdominal. MÉTODO: Utilizando-se o modelo estatístico de regressão logística múltipla, os autores analisaram 110 pacientes com ferida toracoabdominal penetrante, submetidos à drenagem pleural fechada e laparotomia. A complicação empiema pleural foi estudada quanto à incidência e fatores envolvidos. Considerou-se o nível alfa igual a 0,05. RESULTADOS: Do total, 91 (82,7%) pacientes eram do sexo masculino e 19 (17,3%) do feminino. A faixa etária situou-se entre 13 e 63 anos. Os FTA foram causados por projétil de arma de fogo em 60 casos (54,5%) e por arma branca em 50 casos (45,5%). O empiema pleural incidiu em quatro (3,6%) dos pacientes estudados. Na análise estatística a incidência de empiema pleural esteve relacionada com: lesão de víscera oca (OR=3,1386, p=0.4005); lesão do lado esquerdo do diafragma (OR= 12,98, p=0,1178) e choque hemorrágico à admissão (OR=23,9639, p=0,0250). CONCLUSÕES: A chance da ocorrência de empiema pleural foi cerca de três vezes maior em pacientes com lesão de víscera oca e, de 13 vezes se a esta lesão estava associada à lesão do lado esquerdo do diafragma; aumentando para 24 vezes se estes pacientes apresentavam, concomitantemente, estado de choque hemorrágico à admissão.

Video-assisted thoracic surgery: state of the art in trauma care

The majority of chest-injured patients are managed with resuscitation and placement of chest tubes. Further interventions are required for complications or missed injuries. Video-assisted thoracic surgery (VATS) has become standard in elective surgery. Our purpose was to review the use of VATS in trauma. The literature and our experience support the use of VATS for specific indications. These indications are: (1) management of retained haemothorax; (2) management of persistent pneumothorax; (3) evaluation of the diaphragm in penetrating thoraco-abdominal injuries and management; (4) management of infected pleural space collections; and (5) diagnosis and management of on-going bleeding in haemodynamically stable patients. VATS for specific indications in trauma is associated with improved outcomes and decreased length of stay. VATS provides diagnostic and therapeutic benefit and should be included in the trauma surgeon's clinical armamentarium.

The Natural History of Stab Wounds of the Diaphragm: Implications for a New Management Scheme for Patients with Penetrating Thoracoabdominal Trauma

For most patients with abdominal stab wounds expectant management has become the norm. Thoracoabdominal stab wounds, however, raise concern about possible diaphragmatic injury, and diagnostic minilaparotomy, laparoscopy, or thoracoscopy have been advocated in such patients. The present study examined the natural course of an untreated diaphragmatic stab wound. With Institutional Review Board approval eight 25- to 30-kg anesthetized pigs underwent a small upper-midline laparotomy. A 1.5- to 2-cm incision was made in each diaphragm—in the muscular portion on one side and in the tendinous area on the other side. Thereafter a 12-F catheter was placed into each thoracic cavity and attached to suction to resolve pneumothoraces. The laparotomy incision was closed, and the thoracic catheters were removed. Six weeks later the animals were reanesthetized, and the diaphragmatic stab wounds were examined at laparotomy. Fifteen of the 16 (93.8 per cent) diaphragmatic wounds were completely healed. All eight stab wounds in the muscular portion of either diaphragm healed spontaneously. In one animal there was a persistent defect in the tendinous portion of the left diaphragm at the site of the stab wound. The tip of the left lateral segment of the liver and the superior pole of the spleen were found in the defect at laparotomy. We conclude that the vast majority of stab wounds to either the muscular or tendinous diaphragm heal spontaneously. Thus invasive procedures to assess the status of the diaphragm in all patients with thoracoabdominal stab wounds is unwarranted.

[Videothoracospy in thoracic trauma and penetrating injuries]

Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.

The role of videothoracoscopy in management of precordial thoracic penetrating injuries

OBJECTIVES

To report on the value of diagnostic videothoracoscopy in patients with possible penetrating cardiac wounds.

METHODS

Thirteen patients admitted over a 4 year period with hemodynamic stability and a penetrating injury in cardiac proximity had exploratory videothoracoscopy. All data related to those patients were retrospectively reviewed.

RESULTS

Eighty-five percent of patients had videothoracoscopy within 8 h of trauma. In most cases (eight of 13), operations were performed on patients in the supine position with the chest slightly rotated. Nine patients had a left hemothorax, five had pulmonary lacerations and five had a bleeding parietal vessel. Pericardial exploration was achieved either by direct vision (nine patients), or by the performance of a pericardial window (four patients). Acute hemopericardium related to a cardiac wound was diagnosed in two patients. Procedures included evacuation of clotted hemothorax (six patients), stapling of pulmonary laceration (four patients), and electrocoagulation of bleeding parietal vessel (four patients). Four patients required conversion to thoracotomy: two for repair of a cardiac wound, one for adequate exposure of the pericardium and one for ligation of a bleeding intercostal artery. The mean operative time was 37+/-23 min. Two patients experienced postoperative complications (coagulopathy, subcutaneous emphysema) and the in-hospital mortality was 0%. The mean hospital stay was 10+/-4 days.

CONCLUSIONS

In the hands of an experienced surgeon, videothoracoscopy may represent a valid alternative to subxiphoid pericardial window in patients with hemodynamic stability and a suspected cardiac wound. Videothoracoscopy can rule out a cardiac injury and allows for the performance of associated procedures such as diaphragm assessment/repair, evacuation of clotted hemothorax, hemostasis of parietal vessels or pulmonary laceration and removal of projectiles.

Timing, Safety, and Efficacy of Thoracoscopic Evacuation of Undrained Post-Traumatic Hemothorax

Residual post-traumatic hemothorax (RPTH) occurs in 3 to 8 per cent of patients with tube thoracostomy and may cause serious infectious complications. Surgical evacuation is recommended, and thoracoscopic evacuation (THEVA) tends to replace open thoracotomy for this purpose. The objective of this study is to evaluate the optimal timing, safety, and efficacy of THEVA. Over 5 years patients with tube thoracostomy for trauma who had unresolved opacities on plain chest radiograph were evaluated by CT. If the residual fluid volume was estimated to be more than 500 mL3 on CT the patients were offered THEVA. Unstable patients were excluded. A score ranging from one (easy) to three (difficult) was used to grade the difficulty of the operation according to the attending surgeon's perception. Of 1728 chest trauma patients 143 (8%) were evaluated by CT for persistent opacity on plain film, 31 (1.8%) were found to have RPTH, and 24 (1.4%) were eventually taken for THEVA at 3.5 ± 2 days after admission. Low oxygen saturation (less than 94%) was found in 58 per cent of patients before THEVA but in only 25 per cent after THEVA ( P = 0.02). The majority of chest tubes (75%) were removed within 4 days of the operation. Two patients required conversion to thoracotomy. THEVA done within 3 days of admission was associated with a lower operative difficulty score, shorter hospital stay, and a trend toward shorter intraoperative time compared with THEVA done after 3 days of admission. All patients had effective resolution of their radiographic opacities after THEVA. Three patients developed a complication (urinary tract infection, pneumonia, and persistent air leak). We conclude that patients with significant RPTH and without major physiologic compromise are appropriate candidates for THEVA. The procedure is safe, evacuates PRTH effectively, and improves the respiratory function of affected patients. Ideally it should be performed within 3 days of admission.

Penetrating thoracic trauma in arrow injuries

Arrow wounds are very rare. We present herein a case of hilar penetrating thoracic trauma caused by an arrow, and a review of the literature, to clarify the management of these cases and their indications for surgery. Depending on the type of arrowhead, the tissue elasticity can narrow the wound track around the shaft of the arrow, sometimes causing a tamponade effect. In the mediastinal or hilar area, an arrow should not be removed before an injury to the major blood vessels or the heart has been ruled out.

Videotoracoscopia no trauma de tórax

OBJETIVOS: Com o intuito de definir a função da videotoracoscopia no diagnóstico e tratamento no trauma torácico, foram estudados 51 traumatizados por traumas penetrantes ocasionados por arma branca, ferimentos por projétil de arma de fogo ou traumas fechados do tórax, com suspeita diagnóstica por exame clínico e/ou radiológico de lesões torácicas. MÉTODOS: Foram selecionados doentes estáveis vítimas de trauma torácico (pressão arterial sistólica igual ou superior a 90mmHg) com diagnóstico de: hemotórax em 20 (cinco hemotórax estacionários, quatro hemotórax progressivos e 11 hemotórax coagulados), contusões e ferimentos precordiais (três), ferimentos da zona de transição tóraco-abdominal (24), corpo estranho no tórax (dois) e ferimentos transfixantes do mediastino (dois). Todos foram submetidos à videotoracoscopia. RESULTADOS: A videotoracoscopia se mostrou eficiente na investigação diagnóstica nos casos de hemotórax progressivo (quatro casos), hemotórax coagulado (11 casos), contusões e ferimentos precordiais (três casos), ferimentos da zona da transição tóraco-abdominal (confirmação de nove lesões diafragmáticas em 24 traumatizados examinados, 37,5%) e corpos estranhos no tórax, retirada do corpo estranho com sucesso (dois casos). O procedimento também foi eficiente, além do diagnóstico, no tratamento de hemotórax progressivo (ligadura de artéria mamária um caso, cauterização de vasos intercostais um caso), hemotórax coagulado (remoção de coágulos e decorticação, 11 casos) tendo evitado a realização de toracotomia em 33,3% dos traumatizados examinados. CONCLUSÕES: A videotoracoscopia é método eficiente para diagnóstico e tratamento no traumatismo do tórax e ainda pode evitar a toracotomia em expressivo número de pacientes submetidos ao procedimento.

Penetrating chest injuries in the firearm era

BACKGROUND

firearm wounds of the chest are now common at our institution. The management algorithm for firearm wounds has not been evaluated for this mode of injury.

METHODS

records of all patients with penetrating chest injuries admitted to an urban tertiary hospital over 1 year were retrieved and analysed.

RESULTS

there were 473 stab and 116 firearm wounds. In comparison to stab injuries firearm wounds had significantly more normal X-rays (14 vs. 5%), fewer pneumothoraces (15 vs. 37%), and more contusions (43 vs. 2%). The frequency of haemothoraces (34 vs. 23%) and haemopneumothoraces (36 vs. 35%) was similar in both groups. Stabbing caused all the 18 cardiac injuries. Associated abdominal injuries occurred in 8% of stab and 34% of firearm injuries. Pneumothoraces due to firearms were uncommon and rarely required drainage. More pneumothoraces were treated nonoperatively among firearm injuries in contrast to stabbing injuries where the opposite applied. The management of haemothorax and haemopneumothorax was similar in both groups that fulfilled the criteria for drainage. The rate of ICU admission was higher and the hospital-stay longer following firearm injuries. Fifty-nine patients died (10% of the total), 33 (28%) from the firearm injuries and 26 (6%) from stab-wounds. Early deaths were 1 and 3% for stabs and firearms, respectively.

CONCLUSIONS

patients with firearm injuries reaching hospital suffered three times higher mortality and a longer ICU and hospital stay than those with stab injuries. However, early mortality was similar for both modes of injury and validates the continued application of the stab wound derived management algorithm to all modes of injury.

Video thoracoscopy expedites the diagnosis and treatment of penetrating diaphragmatic injuries

BACKGROUND

The diagnostic workup in stable patients with penetrating thoracoabdominal injuries can be extremely difficult. Conventional diagnostic tests such as plain chest radiography, computed tomography scan, digital exploration, and diagnostic peritoneal lavage can be misleading. Classically, most of these patients have undergone exploratory laparotomy to determine whether there is a diaphragmatic injury.

METHODS

In this study, 52 patients with penetrating thoracoabdominal trauma, and without any indication for immediate surgery, underwent video-assisted thoracoscopy to determine the presence of diaphragmatic injuries.

RESULTS

Of the 52 patients, 48 were men. The left hemithorax was involved in 38 patients (73%). Chest x-ray was normal in 40 patients (77%) who were clinically asymptomatic. Stab wounds were responsible for 80% of the injuries. At the time of the thoracoscopy, 35 patients (67%) were found to have a diaphragmatic injury. All 35 diaphragmatic injuries were successfully repaired thoracoscopically. The procedure was completed in 50 patients (96%). There were no deaths or complications.

CONCLUSIONS

The incidence of diaphragmatic injuries is higher than anticipated in asymptomatic patients with penetrating thoracoabdominal wounds. Video thoracoscopy can be used as a safe, expeditious, minimally invasive, and extremely useful technique to facilitate the diagnosis of these injuries in asymptomatic patients. Furthermore, diaphragmatic injuries can be repaired easily through a thoracoscopic approach with no complications.

Conservative management of penetrating torso trauma

Trauma has evolved as a specialty of its own over the past two decades, and has been the subject of much research and a huge number of trials, many of which are ongoing. As a result, it is now possible to apply an evidence-based practice to many trauma scenarios. The management of penetrating injuries to the chest or abdomen has traditionally followed a policy of emergency surgery as the first course of action. This has now shown to be unnecessary in many cases, particularly with the advances in diagnostic tests and imaging modalities. A large number of cases of penetrating torso trauma may require an operation at some stage, but obtaining the clearest diagnostic picture and optimizing the clinical condition of the patient before this undertaking will result in improved outcome. A selective approach to emergency surgery, with its attendant difficulties, is now recommended

Imaging of penetrating thoracic trauma

The management of penetrating chest injuries has evolved significantly over the past few years, with an increasing emphasis on less invasive diagnostic and therapeutic modalities. Only 15% of patients need a therapeutic operative procedure. The challenge is to detect and treat these injuries rapidly while maximizing the use of noninvasive examinations and decreasing costs. The areas potentially at risk for injury include the heart, major vessels, thoracoabdomen, neck, spine, and aerodigestive tract. A review of injuries to these areas, including the use of new diagnostic modalities such as echocardiography and computed tomography (CT) scans, are discussed.

Surgical embryology and anatomy of the diaphragm with surgical applications

This article reviews the development, surgical anatomy, and teratology of the diaphragm, and discusses the diagnostic procedures, surgical therapy, and prognosis of congenital disturbances. Special attention is paid to the traumatic rupture of the diaphragm, concerning incidence, cause, diagnosis, prognosis, and surgical repair.

Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest

BACKGROUND

To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest who lack indications for exploratory celiotomy other than the potential for a diaphragm injury.

STUDY DESIGN

Patients with penetrating injuries to the left lower chest who were hemodynamically stable and without indications for a celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia.

RESULTS

One-hundred-ten patients (94 stab wounds, 16 gunshot wounds) were evaluated with laparoscopy. Twenty-six (24%) diaphragmatic injuries were identified (26% for stab wounds and 13% for gunshot wounds). Comparison of patients with diaphragmatic injuries with those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% versus 24%, NS). The incidence of diaphragmatic injuries in patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injuries in only 1 of 7 patients (14%). The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries (22%, 27%, and 22% respectively).

CONCLUSIONS

The incidence of occult diaphragmatic injuries in penetrating trauma to the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest who do not have any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury.

Therapeutic thoracoscopy

Thoracoscopy provides a minimally invasive window to the pleural space, lung, and mediastinum. Further advances prompted by improvements of specifically designed endoscopic instruments and procedural techniques are expected. There is no doubt that thoracoscopy has a place among therapeutic procedures in the chest. The time-proven principles of thoracic surgical intervention, particularly in regard to patients with cancer, however, must not be neglected. A beckoning window always offers new opportunities, but the open door of classic surgical techniques should not be ignored.

Penetrating thoracoabdominal trauma

Penetrating injuries to the thoracoabdominal region represent a complex and diverse population of injuries. The clinician managing such cases must be able to consider all potential injuries, rapidly recognize life-threatening sequelae, and precisely diagnose and quickly manage these patients. The diverse nature of some of the potential presentations of patients with penetrating thoracoabdominal trauma is discussed. The most recent advances and controversies involving the evaluation and management of patients with penetrating thoracoabdominal trauma are also discussed.

Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial

BACKGROUND

Failure to adequately evacuate blood from the pleural space after trauma may result in extended hospitalization and complications such as empyema.

METHODS

Patients with retained hemothoraces were prospectively randomized to either a second tube thoracostomy (group 1, n = 24) or video-assisted thoracoscopy (VATS) (group 2, n = 15). Group 1 patients in whom additional tube drainage failed were subsequently randomized to either VATS or thoracotomy. Study end points included duration and costs of hospitalization.

RESULTS

During a 4-year period, 39 patients were entered into the study. Patients in group 2 had shorter duration of tube drainage (2.53 +/- 1.36 versus 4.50 +/- 2.83 days, mean +/- standard deviation; p < 0.02), shorter hospital stay after the procedure (3.60 +/- 1.64 versus 7.21 +/- 5.30 days; p < 0.02), and shorter total hospital stay (5.40 +/- 2.16 versus 8.13 +/- 4.62 days; p < 0.02). Hospital costs were also less in this group ($7,689 +/- 3,278 versus $13,273 +/- 8,158; p < 0.02). There was no mortality in either group. No group 2 patient required conversion to thoracotomy. In 10 group 1 patients additional tube placement failed, and this subset was randomized to VATS (n = 5) or thoracotomy (n = 5). No significant difference in clinical outcome was found between these subgroups.

CONCLUSIONS

In many patients treated only with additional tube drainage (group 1), this therapy fails, necessitating further intervention. Intent to treat with early VATS for retained hemothoraces decreases the duration of tube drainage, the length of hospital stay, and hospital cost. Early intervention with VATS may be a more efficient and economical strategy for managing retained hemothoraces after trauma.

Thoracoscopic retrieval of foreign bodies after penetrating chest trauma

Video-assisted thoracic surgery or thoracoscopy has proved to be valuable in many settings in thoracic surgery. The use of video-assisted thoracic surgery in trauma has been limited, especially with respect to penetrating trauma. We report the use of thoracoscopy to remove intrathoracic fragments of glass and avert the need for a thoracotomy.

Role of videothoracoscopy in chest trauma

BACKGROUND

The aim of this study was to evaluate videothoracoscopic procedures in the setting of chest trauma.

METHODS

We retrospectively analyzed our experience of videothoracoscopy in patients with either blunt trauma or penetrating thoracic injuries.

RESULTS

Forty-three procedures involving 42 patients were performed between July 1990 and April 1996. Indications for videothoracoscopy included suspected diaphragmatic injury (14 patients), clotted hemothorax (12), continued hemothorax (6), persistent pneumothorax (5), intrathoracic foreign body (4), posttraumatic chylothorax (1), and posttraumatic empyema (1 patient). Ten patients (24%) required conversion to thoracotomy. Two patients suffered postoperative pneumonia. There was one perioperative death. Mean hospital stay was 17 days; 21 days for patients with blunt trauma and 13 days for patients with penetrating injuries. There was no procedure-related complication. Videothoracoscopy allowed precocious discharge of patients suffering penetrating injuries and allowed faster recovery in the majority of patients suffering severe blunt trauma.

CONCLUSIONS

Videothoracoscopy appears to be a safe, accurate, and useful approach in selected patients with chest trauma. It is ideal for the assessment of diaphragmatic injuries, for control of chest wall bleeding, for early removal of clotted hemothorax, for treatment of empyema, for treatment of chylothorax, for treatment of persistent pneumothorax, and for removal of intrathoracic foreign body. However, we do not recommend the use of this technique in the setting of suspected great vessel or cardiac injury.

Videothoracoscopy an effective method for evaluating and managing thoracic trauma patients

BACKGROUND

The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients.

METHODS

The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2).

RESULTS

The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient.

CONCLUSIONS

Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.

Evaluation of video-assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries

BACKGROUND

Injury to the diaphragm from penetrating or blunt thoracoabdominal trauma is notoriously difficult to diagnose. Chest radiography, computed tomography scan, contrast studies, diagnostic peritoneal lavage, and laparoscopy are inadequate; thus, celiotomy is commonly performed in patients with suspected diaphragmatic injury. We compared the diagnostic accuracy of video-assisted thoracoscopic surgery (VATS) with that of exploratory celiotomy in the evaluation of diaphragmatic and thoracoabdominal injury.

PATIENTS AND METHODS

Hemodynamically stable patients admitted to a level I trauma center with blunt or penetrating injury to the lower chest or abdomen underwent VATS and subsequent celiotomy under the same general anesthetic. Intraoperative thoracoscopic findings were blinded to the abdominal surgeons.

RESULTS

Twenty-six patients were enrolled in the study over a 12-month period. Diaphragmatic injuries were identified in 8 patients (31%). Videothoracoscopy identified all eight injuries in these patients. Six of the 8 patients (75%) with diaphragmatic injuries sustained associated injury to intrathoracic or intra-abdominal organs. There was no mortality and no procedure-related morbidity. There were no missed injuries in patients who underwent VATS.

CONCLUSIONS

Video-assisted thoracoscopy is a safe, expeditious, and accurate method of evaluating the diaphragm in injured patients, and is comparable in diagnostic accuracy to exploratory celiotomy.