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De Vera CJ, Jacob J, Sarva K, Christudas S, Emerine RL, Florence JM, Akiode O, Gorthy TV, Tucker TA, Singh KP, Azghani AO, Komissarov AA, Florova G, Idell S. Intrapleural Fibrinolytic Interventions for Retained Hemothoraces in Rabbits. Int J Mol Sci 2024; 25:8778. [PMID: 39201465 PMCID: PMC11354762 DOI: 10.3390/ijms25168778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
Bleeding within the pleural space may result in persistent clot formation called retained hemothorax (RH). RH is prone to organization, which compromises effective drainage, leading to lung restriction and dyspnea. Intrapleural fibrinolytic therapy is used to clear the persistent organizing clot in lieu of surgery, but fibrinolysin selection, delivery strategies, and dosing have yet to be identified. We used a recently established rabbit model of RH to test whether intrapleural delivery of single-chain urokinase (scuPA) can most effectively clear RH. scuPA, or single-chain tissue plasminogen activator (sctPA), was delivered via thoracostomy tube on day 7 as either one or two doses 8 h apart. Pleural clot dissolution was assessed using transthoracic ultrasonography, chest computed tomography, two-dimensional and clot displacement measurements, and gross analysis. Two doses of scuPA (1 mg/kg) were more effective than a bolus dose of 2 mg/kg in resolving RH and facilitating drainage of pleural fluids (PF). Red blood cell counts in the PF of scuPA, or sctPA-treated rabbits were comparable, and no gross intrapleural hemorrhage was observed. Both fibrinolysins were equally effective in clearing clots and promoting pleural drainage. Biomarkers of inflammation and organization were likewise comparable in PF from both groups. The findings suggest that single-agent therapy may be effective in clearing RH; however, the clinical advantage of intrapleural scuPA remains to be established by future clinical trials.
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Affiliation(s)
- Christian J. De Vera
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Jincy Jacob
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Krishna Sarva
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Sunil Christudas
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Rebekah L. Emerine
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Jon M. Florence
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Oluwaseyi Akiode
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Tanvi V. Gorthy
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Torry A. Tucker
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA;
| | - Ali O. Azghani
- Department of Biology, The University of Texas at Tyler, 3900 University Boulevard, Tyler, TX 75799, USA;
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Galina Florova
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
| | - Steven Idell
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (J.J.); (K.S.); (S.C.); (R.L.E.); (J.M.F.); (O.A.); (T.V.G.); (T.A.T.); (A.A.K.); (G.F.)
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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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Fantin A, Castaldo N, Palou MS, Viterale G, Crisafulli E, Sartori G, Patrucco F, Vailati P, Morana G, Mei F, Zuccatosta L, Patruno V. Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases. J Thorac Dis 2024; 16:2177-2195. [PMID: 38617786 PMCID: PMC11009601 DOI: 10.21037/jtd-23-1745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/02/2024] [Indexed: 04/16/2024]
Abstract
Background and Objective Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature. Methods Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports. Key Content and Findings MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval. Conclusions MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.
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Affiliation(s)
- Alberto Fantin
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Nadia Castaldo
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Michelangelo Schwartzbaum Palou
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Viterale
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giulia Sartori
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità di Novara, Novara, Italy
- Translational Medicine Department, University of Eastern Piedmont, Novara, Italy
| | - Paolo Vailati
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Giuseppe Morana
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Federico Mei
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Lina Zuccatosta
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Vincenzo Patruno
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
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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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De Vera CJ, Emerine RL, Girard RA, Sarva K, Jacob J, Azghani AO, Florence JM, Cook A, Norwood S, Singh KP, Komissarov AA, Florova G, Idell S. A Novel Rabbit Model of Retained Hemothorax with Pleural Organization. Int J Mol Sci 2023; 25:470. [PMID: 38203639 PMCID: PMC10779131 DOI: 10.3390/ijms25010470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Retained hemothorax (RH) is a commonly encountered and potentially severe complication of intrapleural bleeding that can organize with lung restriction. Early surgical intervention and intrapleural fibrinolytic therapy have been advocated. However, the lack of a reliable, cost-effective model amenable to interventional testing has hampered our understanding of the role of pharmacological interventions in RH management. Here, we report the development of a new RH model in rabbits. RH was induced by sequential administration of up to three doses of recalcified citrated homologous rabbit donor blood plus thrombin via a chest tube. RH at 4, 7, and 10 days post-induction (RH4, RH7, and RH10, respectively) was characterized by clot retention, intrapleural organization, and increased pleural rind, similar to that of clinical RH. Clinical imaging techniques such as ultrasonography and computed tomography (CT) revealed the dynamic formation and resorption of intrapleural clots over time and the resulting lung restriction. RH7 and RH10 were evaluated in young (3 mo) animals of both sexes. The RH7 recapitulated the most clinically relevant RH attributes; therefore, we used this model further to evaluate the effect of age on RH development. Sanguineous pleural fluids (PFs) in the model were generally small and variably detected among different models. The rabbit model PFs exhibited a proinflammatory response reminiscent of human hemothorax PFs. Overall, RH7 results in the consistent formation of durable intrapleural clots, pleural adhesions, pleural thickening, and lung restriction. Protracted chest tube placement over 7 d was achieved, enabling direct intrapleural access for sampling and treatment. The model, particularly RH7, is amenable to testing new intrapleural pharmacologic interventions, including iterations of currently used empirically dosed agents or new candidates designed to safely and more effectively clear RH.
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Affiliation(s)
- Christian J. De Vera
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Rebekah L. Emerine
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - René A. Girard
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Krishna Sarva
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Jincy Jacob
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Ali O. Azghani
- Department of Biology, The University of Texas at Tyler, 3900 University Blvd, Tyler, TX 75799, USA;
| | - Jon M. Florence
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Alan Cook
- Department of Surgery, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (A.C.); (S.N.)
| | - Scott Norwood
- Department of Surgery, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (A.C.); (S.N.)
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA;
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Galina Florova
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Steven Idell
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
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Ramzee AF, Bakhsh Z, Peralta R, Rizoli S, El-Menyar A, Al-Thani H, Chughtai T. Traumatic lung laceration secondary to avulsed lung adhesion - A case report. Trauma Case Rep 2023; 46:100862. [PMID: 37347010 PMCID: PMC10279908 DOI: 10.1016/j.tcr.2023.100862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/23/2023] Open
Abstract
Background Pulmonary lacerations caused by an avulsion force on an adhesion between the lung and chest wall following blunt thoracic injury are very rare. They may result in pneumothorax and/or hemothorax and may not be immediately apparent clinically or radiologically. Case presentation We present the case of a healthy 34-year-old male who sustained blunt thoracic injury. He was clinically stable, and his initial routine images were unremarkable. The patient was discharged home on the same day. He presented a week later with a massive hemothorax requiring surgical intervention which revealed bleeding from an avulsed adhesion between the lung and chest wall. Bleeding was successfully controlled by hemostatic agent, and the patient had an uneventful recovery. Conclusion Hemothorax requiring intervention from an avulsed adhesion may occur following blunt thoracic trauma. Initial imaging and clinical finding may be misleading. Close follow up and adequate patient education should be ensured prior to discharge following seemingly trivial trauma.
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Affiliation(s)
- Ahmed F. Ramzee
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Zeenat Bakhsh
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Trauma and Vascular Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
- Clinical medicine, Weill Cornell Medical college, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Talat Chughtai
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
- Department of Surgery, Qatar University, Hamad Medical Corporation, Doha, Qatar
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Khalaf AEM, Ghoneim AE, Mahmoud AB, Abdelwahab AA. Video assisted thoracoscopic surgery vs thoracotomy in management of post traumatic retained hemothorax: a randomized study. THE CARDIOTHORACIC SURGEON 2023; 31:11. [DOI: 10.1186/s43057-023-00101-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/11/2023] [Indexed: 09/02/2023] Open
Abstract
Abstract
Background
Retained hemothorax is a serious problem that can lead to empyema or fibro-thorax. Evacuation of the retained hemothorax is commonly performed via open thoracotomy. This randomized study was conducted to represent our center's expertise with this issue, we compared the outcomes of video-assisted thoracoscopic surgery (VATS) against open thoracotomy in managing post-traumatic retained clotted hemothorax.
Methods
This prospective randomized research was conducted on sixty cases with posttraumatic remaining clots of at least 500 ml or at least one-third of haemothorax that cannot be evacuated by a chest tube after 72 h of first intervention, as detected by computed tomography imaging who underwent open thoracotomy or VATS in the management of posttraumatic retained clotted hemothorax. Cases were allocated to equal groups; group A: cases who underwent VATS and group B: cases who underwent open thoracotomy.
Results
Preoperative intercostal chest tube (ICT) placement period was insignificantly different between the two groups. Group A had a significantly lesser post-operative amount of ICT drainage, and ICT was removed after significantly fewer days than in group B (P value < 0.001). Post-operatively, the numerical rating scale (NRS) was significantly higher at post-extubation and 6 h after extubation in group B than group A (P value < 0.05) and was insignificantly different between both groups the next morning, after chest tube removal and before discharge. group A had statistically better NRS versus group B (P value < 0.001). Wound infection incidence was significantly less in group A compared to group B (P value = 0.025); the incidence of air leak was insignificantly different between both groups. Group A has significantly shorter hospitalization than group B (P value < 0.001). Wound infection and empyema in outcases were insignificantly different between both groups (P value = 0.492). Cases in group A returned to normal activity earlier than group B (P value < 0.001).
Conclusions
VATS in managing posttraumatic retained hemothorax was a more effective, well-tolerated, and reliable intervention that can be easily utilized for managing posttraumatic retained hemothorax in comparison to open thoracotomy.
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Malkoc A, Phan T, Nguyen DT, Gill H, Phan AT, Cerceo JR, Nguyen A, Lebedevskiy O, Toporoff B. Benefits of Early Thoracic Surgery in the Elderly During the COVID-19 Pandemic: Lessons Learned From Performing a Video-Assisted Thoracotomy. Cureus 2022; 14:e31461. [DOI: 10.7759/cureus.31461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 11/15/2022] Open
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9
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Wu CJ, Liu YY, Tarng YW, Huang FD, Chou YP, Chuang JF. It is Time to Replace Large Drains with Small Ones After Fixation of Rib Fractures: A Prospective Observational Study. Adv Ther 2022; 39:3668-3677. [PMID: 35723830 PMCID: PMC9309127 DOI: 10.1007/s12325-022-02182-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
Abstract
Introduction Large-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS. Methods Overall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared. Results All patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171–10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109–4.888, P = 0.027). Conclusion After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.
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Affiliation(s)
- Chieh-Jen Wu
- Division of Cardiac Surgery, Department of Surgery, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan.,Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Yuan-Yuarn Liu
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung, 813, Taiwan
| | - Yih-Wen Tarng
- Department of Medical Education and Research, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Fong-Dee Huang
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung, 813, 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, 386, Da-Chung 1st Road, Kaohsiung, 813, Taiwan
| | - Jung-Fang Chuang
- Division of Trauma, Department of Emergency, Kaohsiung-Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung, 813, Taiwan.
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10
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Candida Albicans Osteomyelitis after Chest Wall Blunt Trauma: A Case Report. Case Rep Surg 2021; 2021:9987317. [PMID: 34188968 PMCID: PMC8192213 DOI: 10.1155/2021/9987317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/26/2021] [Indexed: 11/17/2022] Open
Abstract
Fungal osteomyelitis is a rare disease that can occur in immunocompromised patients. We report a case of a patient with a primary rib osteomyelitis after a blunt trauma of the chest wall. Aggressive surgical debridement along with antifungal therapy was the cornerstone of the disease management in this patient.
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11
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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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12
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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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13
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Yu MG, Jing R, Mo YJ, Lin F, Du XK, Ge WY, Dai HJ, Hu ZK, Zhang SS, Pan LH. Non-intubated anesthesia in patients undergoing video-assisted thoracoscopic surgery: A systematic review and meta-analysis. PLoS One 2019; 14:e0224737. [PMID: 31714904 PMCID: PMC6850529 DOI: 10.1371/journal.pone.0224737] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Non-intubated anesthesia (NIA) has been proposed for video-assisted thoracoscopic surgery (VATS), although how the benefit-to-risk of NIA compares to that of intubated general anesthesia (IGA) for certain types of patients remains unclear. Therefore, the aim of the present meta-analysis was to understand whether NIA or IGA may be more beneficial for patients undergoing VATS. METHODS A systematic search of Cochrane Library, Pubmed and Embase databases from 1968 to April 2019 was performed using predefined criteria. Studies comparing the effects of NIA or IGA for adult VATS patients were considered. The primary outcome measure was hospital stay. Pooled data were meta-analyzed using a random-effects model to determine the standard mean difference (SMD) with 95% confidence intervals (CI). RESULTS AND DISCUSSION Twenty-eight studies with 2929 patients were included. The median age of participants was 56.8 years (range 21.9-76.4) and 1802 (61.5%) were male. Compared to IGA, NIA was associated with shorter hospital stay (SMD -0.57 days, 95%CI -0.78 to -0.36), lower estimated cost for hospitalization (SMD -2.83 US, 95% CI -4.33 to -1.34), shorter chest tube duration (SMD -0.32 days, 95% CI -0.47 to -0.17), and shorter postoperative fasting time (SMD, -2.76 days; 95% CI -2.98 to -2.54). NIA patients showed higher levels of total lymphocytes and natural killer cells and higher T helper/T suppressor cell ratio, but lower levels of interleukin (IL)-6, IL-8 and C-reactive protein (CRP). Moreover, NIA patients showed lower levels of fibrinogen, cortisol, procalcitonin and epinephrine. CONCLUSIONS NIA enhances the recovery from VATS through attenuation of stress and inflammatory responses and stimulation of cellular immune function.
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Affiliation(s)
- Mei-gang Yu
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Anesthesiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Ren Jing
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yi-jie Mo
- Department of Anesthesiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Fei Lin
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xue-ke Du
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wan-yun Ge
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hui-jun Dai
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhao-kun Hu
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Sui-sui Zhang
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ling-hui Pan
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- * E-mail:
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Srinivasan A, Sivaramakrishnan M, Pattabhiraman VR, Vinod VG. Medical thoracoscopic cryoevacuation: A novel technique to manage retained hemothorax. Lung India 2019; 36:356-359. [PMID: 31290425 PMCID: PMC6625234 DOI: 10.4103/lungindia.lungindia_225_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Hemothorax is an important complication of blunt trauma chest. The presentation may be delayed, especially in elderly patients with multiple rib fractures. Delayed presentation can be associated with retained hemothorax where a simple chest drain is often insufficient to evacuate the pleural cavity. Video-assisted thoracoscopy surgery is often used to manage such patients in a minimally invasive manner. Here, we demonstrate a novel application of flexi-rigid thoracoscopy with CryoProbe® for evacuation of retained hemothorax in an elderly woman through a subcentimeter incision.
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Affiliation(s)
- Arjun Srinivasan
- Department of Pulmonary Medicine, Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India
| | | | | | - V G Vinod
- Department of Pulmonary Medicine, Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India
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15
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Lodhia JV, Konstantinidis K, Papagiannopoulos K. Video-assisted thoracoscopic surgery in trauma: pros and cons. J Thorac Dis 2019; 11:1662-1667. [PMID: 31179111 DOI: 10.21037/jtd.2019.03.55] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Thoracic injuries account for 60% of all trauma presentations. These patients often have extra-thoracic injuries adding to the complexity of their management. Morbidity and the associated mortality are significantly increased in the elderly. The majority of cases will comprise of simple rib fractures, requiring adequate analgesia. In those that require surgical intervention, the use of video-assisted thoracoscopic surgery (VATS) is becoming increasingly more popular. VATS can often provide greater visualisation of the intra-thoracic structures, whilst limiting the burden of injury to smaller non-rib spreading incisions. It is therefore becoming increasingly used as a diagnostic tool to identify the extend of the injuries whilst also allowing for therapeutic intervention. These benefits translate into decreased rate of post-operative complications and a shorter length of inpatient stay. We also discuss the relative contra-indications and cautions to the use of VATS in the setting of trauma.
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Affiliation(s)
- Joshil Vinod Lodhia
- Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Konstantinos Konstantinidis
- Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Kostas Papagiannopoulos
- Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
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17
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Pieracci FM. Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it? J Thorac Dis 2019; 11:S1061-S1069. [PMID: 31205763 DOI: 10.21037/jtd.2019.01.70] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Surgical stabilization of rib fractures (SSRF) is now a common operation at most high-volume trauma centers. Increased experience with the procedure has spawned a variety of technical modifications to minimize incision length, muscle division, scapular retraction, and general tissue trauma. The ultimate example of such a minimally invasive approach is completely thoracoscopic SSRF, which refers to using a video-assisted thoracoscopic surgery (VATS) technique to both reduce and fixate rib fractures in an intra-thoracic fashion. The benefits of thoracoscopic SSRF may be divided broadly into those that relate to the repair of the rib fractures themselves, and those that relate to adjuncts to rib fracture repair. With respect to the former, theoretical benefits include improved visualization of rib fractures (particularly in posterior and sub-scapular locations), minimization of trauma to overlying muscles and nerves, minimization of trauma to intra-thoracic structures, and elimination of palpable plates. With respect to the latter, theoretical advantages include evacuation of retained hemothorax, guided placement of loco-regional anesthesia and chest tubes, and identification and repair of associated, intra-thoracic injuries. A VATS may also aid in trainee education. Despite these theoretical benefits, early attempts at thoracoscopic SSRF have been limited by both user inexperience and inadequate instrumentation. Furthermore, there are currently no data comparing the efficacy of completely thoracoscopic SSRF to either contemporary, minimally-invasive, extra-thoracic SSRF or non-operative management.
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Affiliation(s)
- Fredric M Pieracci
- University of Colorado Health Sciences Center, Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, Denver, CO, USA
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18
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Akil A, Ziegeler S, Reichelt J, Semik M, Müller MC, Fischer S. Rib osteosynthesis is a safe and effective treatment and leads to a significant reduction of trauma associated pain. Eur J Trauma Emerg Surg 2019; 45:623-630. [DOI: 10.1007/s00068-018-01062-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/20/2018] [Indexed: 08/26/2023]
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Lin HL, Tarng YW, Wu TH, Huang FD, Huang WY, Chou YP. The advantages of adding rib fixations during VATS for retained hemothorax in serious blunt chest trauma - A prospective cohort study. Int J Surg 2019; 65:13-18. [PMID: 30878761 DOI: 10.1016/j.ijsu.2019.02.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/05/2019] [Accepted: 02/19/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fracture. Early video-assisted thoracoscopic surgery (VATS) to evacuate retained hemothorax is one commonly used treatment. In this study, a new strategy was implemented to combine VATS with fractured rib fixation simultaneously. METHODS This prospective observational study was performed from January 2013 to April 2018. All patients were aged 18 years or older and had blunt chest trauma with displaced fractures in more than three ribs. No patients had acute respiratory failure within 24 h after trauma. Patients with retained hemothorax who received VATS constituted the study cohort. Subsequently, patients who received rib fixation during VATS procedures were compared with those who did not. Clinical outcomes such as dose of analgesics, and length of hospital stay were recorded. RESULTS During the study period, 128 patients were enrolled. Available demographic characteristics of the 2 groups were compared, and no statistical differences were observed. The rates of shorter temporary ventilator dependence after operations were lower in the rib fixation group (0% vs. 24.7%, P = 0.017). Persistent air leakage more than 5 days after operations were also lower in the rib fixation group (0% vs. 10.4%, P = 0.001). The length of stay in overall hospital stay were longer for patients who received VATS without rib fixation (9.29 ± 2.51 days vs. 12.39 ± 4.65, P = 0.001). Furthermore, the rib fixation group were administered much lower doses of opiates during their hospital stays (52.45 ± 15.67 mg vs. 77.24 ± 50.42 mg, P = 0.001). CONCLUSION Adding rib fixation during VATS in the management of retained hemothorax can contribute to shorten whole treatment courses. Rib fixation can also reduce pain, thus reducing dependence on analgesics.
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Affiliation(s)
- Hsing-Lin Lin
- Department of Critical Care Medicine, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - Yih-Wen Tarng
- Division of Trauma and Fracture, Department of Orthopedics, Kaohsiung-Veterans General Hospital, Kaohsiung, Taiwan
| | - 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
| | - 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
| | - 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.
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20
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Abstract
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.
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Bozzay JD, Walker PF, Ronaldi AE, Elster EA, Rodriguez CJ, Bradley MJ. Tube Thoracostomy Management in the Combat Wounded. Am Surg 2018. [DOI: 10.1177/000313481808400852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The intent of this study was to characterize the management and subsequent complications of combat injury tube thoracostomies and to determine risk factors for the development of pneumonia (PNA) and retained hemothorax (RH). One hundred fifteen patients with 173 tube thoracostomies met the inclusion criteria and were analyzed. The mean injury severity score was 30.8 1 11.6, 23.5 per cent had traumatic amputations, 49.7 per cent had a hemothorax, and 50.3 per cent had a pneumothorax as indications for tube thoracostomy (TT) placement. Within 24 hours of injury, 89.6 per cent were intubated, the majority (54%) were injured by improvised explosive devices, 35.6 per cent sustained rib fractures, and 12.2 per cent had a diaphragm injury. A mean of 1.5 1 0.7(range 1–4) tube thoracostomies were placed, 18.3 per cent of patients had bilateral tube thoracostomies, and the average TT duration was 6.7 1 3.9 days. The incidence of PNA was 27 per cent (n = 31), RH was 9.6 per cent (n = 11), and empyema was 1.7 per cent (n = 2). Multivariable analysis identified the duration of ventilation [OR 1.2, 95% confidence interval (CI): 1.097–1.313, P < 0.001] as independently associated with the development of PNA. Bilateral TT placement (OR 3.848, 95% CI: 1.219–12.143, P = 0.0216) and injury severity score (OR 1.050, 95% CI: 1.001–1.102, P = 0.0443) were independently associated with PNA development when a patient was intubated for eight days or less. The number of tube thoracostomies placed (OR 3.08, 95% CI: 1.03–9.18, P = 0.0439) was independently associated with the development of RH. Further research is warranted to identify modifiable risk factors to reduce the incidence of PNA and RH in patients with TT placed for traumatic injuries.
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Affiliation(s)
- Joseph D. Bozzay
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Patrick F. Walker
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Alley E. Ronaldi
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric A. Elster
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Carlos J. Rodriguez
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew J. Bradley
- From the Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
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22
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Abstract
Introduction Chest injuries occur in a significant portion of trauma patients and hemothorax is a common result. While the initial management of traumatic hemothorax is most commonly treated with tube thoracostomy, the management of retained hemothorax is a subject of debate. Recent literature has proposed different methods for treating or preventing retained hemothorax, yet the approach to this pathology is not straightforward. Methods The literature was reviewed for relevant studies regarding the prevention and management of post-traumatic retained hemothorax. What follows is a review of the recent literature and an algorithm for the approach to treating a traumatic retained hemothorax. Results Identifying a traumatic retained hemothorax and preventing subsequent complications such as pneumonia, empyema, and fibrothorax are significant issues faced by surgeons. Studies for preventing retained hemothorax have focused on initial chest tube size, location, and peri-procedural placement conditions, as well as thoracic lavage. Several treatment modalities exist, including second drainage procedure and intra-pleural fibrinolytic drug instillation, but video-assisted thoracoscopic surgery is the most common and successful approach. Regardless of the approach to evacuation, early intervention is paramount. Conclusion Further studies will help characterize appropriate candidates, timing, treatment modalities, and guide therapy for retained hemothorax.
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Affiliation(s)
- Joseph D Bozzay
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
| | - Matthew J Bradley
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Naval Medical Research Center, Silver Spring, MD, USA
- Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
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23
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Lichte P, Kalverkamp S, Spillner J, Hildebrand F, Kobbe P. [Chest trauma from a surgical perspective]. Unfallchirurg 2018; 121:403-412. [PMID: 29651513 DOI: 10.1007/s00113-018-0494-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Patients with multiple injuries in particular frequently also suffer from chest trauma. During the initial phase the identification and treatment of life-threatening injuries is essential and tension pneumothorax is of particular importance during this phase. The Advanced Trauma Life Support (ATLS) algorithm should be followed for structured treatment. In most cases treatment by insertion of a chest tube is sufficient but for some injuries an emergency thoracotomy is unavoidable as a life-saving intervention. In the further treatment especially a flail chest and retained hemothorax are responsible for complications, such as acute lung failure and thoracic empyema. Early operative interventions in the sense of rib fracture stabilization and thoracoscopy-assisted evacuation of hematomas can help to prevent such complications.
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Affiliation(s)
- Philipp Lichte
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Sebastian Kalverkamp
- Klinik für Thorax‑, Herz- und Gefäßchirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Jan Spillner
- Klinik für Thorax‑, Herz- und Gefäßchirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Frank Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Philipp Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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24
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Minimized approaches to the posterolateral chest wall in the fixation of rib fracture. Eur J Trauma Emerg Surg 2018; 44:483. [PMID: 29626216 DOI: 10.1007/s00068-018-0931-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
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Abstract
Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.
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Affiliation(s)
- Corinna Ludwig
- Department of Thoracic Surgery, Florence Nightingale Hospital, Düsseldorf, Germany
| | - Aris Koryllos
- Department of Thoracic Surgery, Private University Witten-Herdecke, Metropolitan Hospital of Cologne Merheim, Cologne, Germany
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26
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Efficiency Analysis of Direct Video-Assisted Thoracoscopic Surgery in Elderly Patients with Blunt Traumatic Hemothorax without an Initial Thoracostomy. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3741426. [PMID: 27190987 PMCID: PMC4850251 DOI: 10.1155/2016/3741426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/14/2016] [Indexed: 01/10/2023]
Abstract
Hemothorax is common in elderly patients following blunt chest trauma. Traditionally, tube thoracostomy is the first choice for managing this complication. The goal of this study was to determine the benefits of this approach in elderly patients with and without an initial tube thoracostomy. Seventy-eight patients aged >65 years with blunt chest trauma and stable vital signs were included. All of them had more than 300 mL of hemothorax, indicating that a tube thoracostomy was necessary. The basic demographic data and clinical outcomes of patients with hemothorax who underwent direct video-assisted thoracoscopic surgery without a tube thoracostomy were compared with those who received an initial tube thoracostomy. Patients who did not receive a thoracostomy had lower posttrauma infection rates (28.6% versus 56.3%, P = 0.061) and a significantly shorter length of stay in the intensive care unit (3.13 versus 8.27, P = 0.029) and in the hospital (15.93 versus 23.17, P = 0.01) compared with those who received a thoracostomy. The clinical outcomes in the patients who received direct VATS were more favorable compared with those of the patients who did not receive direct VATS.
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