Life threatening hemoperitoneum and liver injury as a result of chest tube thoracostomy

External Validation of a Tube Thoracostomy Complication Classification System

BACKGROUND

Tube thoracostomy (TT) is a commonly performed procedure which is associated with significant complication rates. Currently, there is no validated taxonomy to classify and compare TT complications across different populations. This study aims to validate such TT complication taxonomy in a cohort of South African trauma patients.

METHODS

Post hoc analysis of a prospectively collected trauma database from Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa was performed for the period January 2010 to December 2013. Baseline demographics, mechanism of injury and complications were collected and categorized according to published classification protocols. All patients requiring bedside TT were included in the study. Patients who necessitated operatively placed or image-guided TT insertion were excluded. Summary and univariate analyses were performed.

RESULTS

A total of 1010 patients underwent TT. The mean age was (±SD) of 26 ± 8 years. Unilateral TTs were inserted in n = 966 (96%) and bilateral in n = 44 (4%). Complications developed in 162 (16%) patients. Penetrating injury was associated with lower complication rate (11%) than blunt injury (26%), p = 0.0001. Higher complication rate was seen in TT placed by interns (17%) compared to TT placed by residents (7%), p = 0.0001. Complications were classified as: insertional (38%), positional (44%), removal (9%), infective/immunologic (9%), and instructional, educational or equipment related (0%).

CONCLUSIONS

Despite being developed in the USA, this classification system is robust and was able to comprehensively assign and categorize all the complications of TT in this South African trauma cohort. A universal standardized definition and classification system permits equitable comparisons of complication rates. The use of this classification taxonomy may help develop strategies to improve TT placement techniques and reduce the complications associated with the procedure.

LEVEL OF EVIDENCE

V.

STUDY TYPE

Single Institution Retrospective review.

Unusual Malposition of a Chest Tube, Intrathoracic but Extrapleural

Chest tube malpositioning is reported to be the most common complication associated with tube thoracostomy. Intraparenchymal and intrafissural malpositions are the most commonly reported tube sites. We present a case about a 21-year-old patient with cystic fibrosis who was admitted due to bronchiectasis exacerbation and developed a right-sided pneumothorax for which a chest tube was inserted. Partial initial improvement in the pneumothorax was noted on the chest radiograph, after which the chest tube stopped functioning and the pneumothorax remained for 19 days. Chest computed tomography was done and revealed a malpositioned chest tube in the right side located inside the thoracic cavity but outside the pleural cavity (intrathoracic, extrapleural). The removed chest tube was patent with no obstructing materials in its lumen. A new thoracostomy tube was inserted and complete resolution of the pneumothorax followed.

Successful Balloon-Assisted Hepatic Tract Embolization Using the Pull-Through Technique to Remove a Malpositioned Chest Tube Penetrating the Liver and into the Right Ventricle

Intra-abdominal injury is an uncommon complication of chest tube insertion. A 66-year-old man had empyema and underwent chest tube insertion for drainage. Massive hemorrhage occurred; the postprocedural radiograph showed the malpositioned chest tube in the mediastinum. Computed tomography scan showed that the tube's tip penetrated through the liver capsule and passed through the hepatic vein to the right ventricle. Hepatic tract embolization with coiling was performed during chest tube removal under a controlled condition with the hepatic tract occluded by a balloon catheter. The balloon catheter was placed from the right jugular vein using the pull-through technique, establishing a through-and-through guidewire. This is the first report of successful removal of a chest tube malpositioned in the hepatic vein by balloon-assisted hepatic tract embolization without complication.

Liver injury secondary to chest tube placement: a case report of conservative management and review of literature

Chest tube placement is a routine procedure performed in different medical departments. Liver injury is a very rare complication that can occur but can be life‐threatening. Conservative management can be proposed in stable patient. Following guidelines and training physicians should decrease the incidence of such complications.

Noninvasive management for iatrogenic splenic injury caused by chest tube insertion: a case report

Splenic injury is one of the most critical complications of chest tube insertion and often requires invasive emergency management. However, noninvasive management such as delayed removal of the malpositioned tube may be considered for a stable patient without severe adverse event.