Surgical outcomes after trauma pneumonectomy: Revisited

Damage control thoracic surgery: What you need to know

ABSTRACT

Damage control surgery in trauma prioritizes patient stabilization through an initial temporizing surgical approach to rapidly control hemorrhage and contamination, minimizing intraoperative time to allow for resuscitation and the correction of hypothermia, coagulopathy, and acidosis in the intensive care unit. This is followed by definitive repair of injuries once physiological parameters have improved. While damage control techniques for traumatic intra-abdominal and extremity injuries are well established and frequently utilized, the same cannot be said for damage control thoracic surgery. The complexity of thoracic injuries, the intricate decision making process, the level of surgical expertise required, and potential complications make damage control thoracic surgery particularly challenging. However, advances in surgical techniques, improvements in perioperative care, and the emergence of adjuncts such as extracorporeal membrane oxygenation have significantly enhanced decision making and underscored the importance of timely and decisive intervention in damage control thoracic surgery to optimize patient outcomes. This review aims to provide a comprehensive overview of damage control thoracic surgery, detailing the principles, indications, operative techniques, perioperative management, and the integration of advanced therapies to improve outcomes in patients with severe thoracic injuries.

The Harsh Reality: Outcomes of Patients With Operatively Managed Lung Injuries

INTRODUCTION

Most traumatic lung injuries are managed non-operatively. There is a paucity of recent data on the outcomes of operatively managed lung injuries. The aim of our study is to determine the survival rates of operatively managed traumatic lung injury patients on a nationwide scale.

METHODS

We performed a retrospective analysis of the ACS-TQIP 2017-2020. We included all adult trauma patients with lung injuries that underwent operative management. Patients were stratified based on type of surgery into 3 groups (wedge resection, lobectomy, pneumonectomy). The outcome was mortality. Multivariable logistic regression analysis was performed to identify the independent predictors of mortality.

RESULTS

We identified a total of 170,377 patients with lung injuries, out of which 2159 (1.3%) patients underwent operative management (Wedge resection [61%], Lobectomy [31%], Pneumonectomy [8%]). Among operatively managed patients, the mean (SD) age was 37 (16) years, and 86% were male. Overall, 65% sustained penetrating injuries, with a median [IQR] ISS of 25 [16 - 33], and median [IQR] lung injury AIS severity of 4 [3 - 4]. About 7% of the patients suffered hilar injuries. The mean (SD) SBP on arrival was 108 (43) and the median [IQR] time to surgery was 177 [52 - 5351] minutes. The median hospital LOS was 10 [1 - 19] days, and overall mortality rate was 30%. On univariate analysis, patients undergoing pneumonectomy had the highest mortality (54%), followed by lobectomy (33%), and wedge resection (25%). On multivariable regression analysis, hilar injuries (aOR 1.9, 95%CI = 1.06 - 2.80, P = 0.029), increasing age (aOR 1.02, 95%CI = 1.01 - 1.03, P = 0.001), concomitant head (aOR 1.34, 95%CI = 1.22 - 1.47, P < 0.001) and abdominal injuries (aOR 1.42, 95%CI = 1.31 - 1.54, P < 0.001) were independent predictors of mortality.

CONCLUSIONS

Nearly 1 in 3 patients with lung injuries who were managed operatively did not survive their index admission. These findings highlight that operatively managed lung injuries still carry a high risk of mortality and should be reserved for selected patients. The decision for surgery in patients with concomitant head or abdominal injuries must be taken on a case-to-case basis.

Penetrating thoracic injury requiring emergency pneumonectomy supported with two ECMO runs: A testament to multidisciplinary critical care medicine

Post-traumatic pneumonectomies are uncommon and, if necessary, carry significant mortality. The use of extracorporeal membrane oxygenation (ECMO) for lung injury in trauma patient has demonstrated efficacy with minimal bleeding complications. We report a case of a young man with a penetrating thoracic injury that required a pneumonectomy supported with two separate ECMO runs for pulmonary failure postoperatively.

Hybrid extracorporeal membrane oxygenation (ECMO) cannulation following traumatic pneumonectomy: A case report

A 28-year-old man presented in extremis after a motorcycle crash. Following traumatic pneumonectomy, he developed right heart failure and was placed on veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) only to transition to veno-arteriovenous (VAV) ECMO due to persistent hypoxemia. Resulting flow limitation caused distal ischemia of his left leg, requiring thrombectomy and fasciotomy. Potential loss of limb necessitated transitioning to veno-venous (VV) ECMO from which he was successfully decannulated thereafter. ECMO can bridge recovery following the most dire injuries, and hybrid strategies can ameliorate post-operative complications; however, ECMO itself carries significant risks that must be weighed against intended benefit.

Arterial Bullet Embolization Secondary to Direct Cardiac Injury in Penetrating Chest Trauma: A Rare Challenging Case Report

Severe thoracic injury secondary to penetrating trauma requires prompt resources and rapid decision-making by trauma centers and teams. Implementing trauma systems has significantly impacted medical and critical care quality and outcomes, including managing rare trauma injuries. We describe a report of a rare case of a 21-year-old man with a gunshot wound to the chest with injuries to the right pulmonary hilum requiring pneumonectomy and to the left atrium with bullet embolism to the right common iliac artery. In addition, the systematic approach where each phase of the individual's treatment -- prehospital, emergency room, running room, and intensive care -- was positively affected by the implementation, development, and progressive maturation of a trauma system is also explained.

Drug Regimen for Patients after a Pneumonectomy

Pneumonectomy is an entire lung removal and is indicated for both malignant and benign diseases. Due to its invasiveness and postoperative complications, pneumonectomy is still associated with high mortality and morbidity. Appropriate postoperative management is crucial in pneumonectomy patients to improve quality of life and overall survival rates. Diverse drug regimens are under development to be used in adjuvant chemotherapy or to improve respiratory health after a pneumonectomy. The most common causes for a pneumonectomy are non-small cell lung cancer, malignant pleural mesothelioma, and tuberculosis; thus, an appropriate drug regimen is necessary. The uncommon incidence of pneumonectomy cases remains the major obstacle in studies of postoperative drug regimens. As the majority of current studies include post-lobectomy and post-segmentectomy patients, it is highly recommended that further research of postoperative drug regimens be focused on post-pneumonectomy patients.

The tenets of intrathoracic packing during damage control thoracic surgery for trauma patients: a systematic review

PURPOSE

Although Damage Control Thoracic Surgery (DCTS) has become a provocative alternative to treat patients with chest injuries who are critically ill and physiologically depleted, the management approaches of chest-packing and the measurement of clinically relevant outcomes are not well established. In this paper, we systematically reviewed the available knowledge and evidence about intra-thoracic packing during DCTS for trauma patients. We furthermore inform on the management approaches, surgical strategies, and mortality associated with this intervention.

METHODS

We identified articles in MEDLINE and SCOPUS. We reviewed all studies that included trauma patients with chest injuries and managed with intrathoracic packing during DCTS. Studies were eligible if the use of intrathoracic packing in trauma populations was reported.

RESULTS

We identified 14 studies with a total of 211 patients. Overall, intrathoracic packing was used in 131 trauma patients. Packing was most commonly used to arrest persistent coagulopathic bleeding or oozing either from raw surfaces or repaired structures and in conjunction with other operative techniques. Pneumonectomy was a deadly intervention; however, one study reported survivors when pneumonectomy was deferred.

CONCLUSION

Packing is a feasible, reliable and potentially effective complementary method for hemorrhage control. Therefore, we recommend that packing can be used liberally as a complement to rapid lung-sparing techniques.

Lung Resection for Trauma: A Propensity Score Adjusted Analysis Comparing Wedge Resection, Lobectomy, and Pneumonectomy

The resection of lung parenchyma for thoracic trauma is uncommon. Different surgical procedures with a wide range of complexities have been described depending on the severity of trauma and the presence of associated injuries. The aim of this study was to analyze outcomes of wedge resection, lobectomy, and pneumonectomy. Data for this study were obtained from an eight-year retrospective National Trauma Data Bank study (2007–2015). Adult patients who sustained severe chest trauma (Abbreviated Injury Scale > 3) that required any type of lung resection were included. Propensity score (PS) analysis was adopted. Overall, 3107 patients were included. Wedge resection was performed in 54.3 per cent, lobectomy in 38.2 per cent, and pneumonectomy in 7.5 per cent of patients. Longer in-hospital length of stay ( P = 0.01), ICU length of stay ( P = 0.002), and mechanical ventilation days ( P = 0.038) were found in case of major resections. The overall morbidity and mortality were 32 per cent and 27.5 per cent, respectively. A stepwise increase in mortality occurred when comparing wedge (20.3%), lobectomy (30.8%), and pneumonectomy (63.4%) ( P < 0.001). After PS analysis, lobectomy and pneumonectomy were associated with higher mortality compared with wedge resection (odds ratio [OR] 1.42; 95% confidence interval 1.26–1.71 and OR 4.16; 95% confidence interval 2.84–6.07, respectively). Similarly, after PS analysis, lobectomy and pneumonectomy were associated with higher overall complications compared with wedge resection (OR 1.21 and OR 1.56, respectively). Comparable results were found in the subgroup analysis of patients with isolated lung injury. After PS matching, lobectomy and pneumonectomy were associated with significantly higher morbidity and mortality compared with nonanatomical wedge resection.

Outcomes after pneumonectomy versus limited lung resection in adults with traumatic lung injury

Pneumonectomy after traumatic lung injury (TLI) is associated with shock, increased pulmonary vascular resistance, and eventual right ventricular failure. Historically, trauma pneumonectomy (TP) mortality rates ranged between 53 and 100%. It is unclear if contemporary mortality rates have improved. Therefore, we evaluated outcomes associated with TP and limited lung resections (LLR) (i.e., lobectomy and segmentectomy) and aimed to identify predictors of mortality, hypothesizing that TP is associated with greater mortality versus LLR. We queried the Trauma Quality Improvement Program (2010–2016) and performed a multivariable logistic regression to determine the independent predictors of mortality in TLI patients undergoing TP versus LLR. TLI occurred in 287,276 patients. Of these, 889 required lung resection with 758 (85.3%) undergoing LLR and 131 (14.7%) undergoing TP. Patients undergoing TP had a higher median injury severity score (26.0 vs. 24.5, p = 0.03) but no difference in initial median systolic blood pressure (109 vs. 107 mmHg, p = 0.92) compared to LLR. Mortality was significantly higher for TP compared to LLR (64.9% vs 27.2%, p < 0.001). The strongest independent predictor for mortality was undergoing TP versus LLR (OR 4.89, CI 3.18–7.54, p < 0.001). TP continues to be associated with a higher mortality compared to LLR. Furthermore, TP is independently associated with a fivefold increased risk of mortality compared to LLR. Future investigations should focus on identifying parameters or treatment modalities that improve survivability after TP. We recommend that surgeons reserve TP as a last-resort management given the continued high morbidity and mortality associated with this procedure.

Trauma pneumonectomy: A narrative review

PURPOSE

Thoracic injuries are common in both blunt and penetrating trauma. Most thoracic injuries are managed non-operatively, approximately 7-20% undergo thoracotomy. Of the injuries requiring thoracotomy, 1-6% ultimately require pulmonary resection. Wedge resection and lobectomies are well-studied in the literature; however, there is a paucity regarding reports on total pneumonectomy in the setting of trauma. Our objectives were to summarize the evidence supporting the role of trauma pneumonectomy (TP) in the current era and reiterate that despite the associated morbidity and mortality TP is justified in selective cases.

METHODS

A review of the world's literature was conducted following standard guidelines. Inclusion criteria included those studies reviewing blunt and penetrating trauma to the lungs in adults (age greater than 15 year) that reported mortality rates and outcome measures.

RESULTS

The PubMed search yielded 713 studies. Of these, 14 studies included pertinent information on TP. Studies included in this review were published from 1985 to 2017 and involved patient data that was collected from 1972 to 2014. Mortality ranged from 50% to 100% (median 63%; mean 68%).

CONCLUSION

In the setting of severe thoracic trauma, pulmonary resection may be necessary. Less aggressive techniques are options in a stable patient; however, in the setting of ongoing hemorrhage, TP should be considered and expediently conducted. The role of damage control thoracic surgery and related techniques is vitally important in these patients to improve the significant mortality of trauma pneumonectomy.