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.(Ann Thorac Surg 1997;63:327–33)© 1997 by The Society of Thoracic Surgeons     

Endovascular repair of aortic lesions associated to video-assisted thoracoscopy surgery after chest trauma

AIM: Trauma of the thoracic aorta for blunt trauma shows a very high incidence of mortality. Hospital mortality rate after aortic open surgery is between 15% and 30%. Endovascular management represents an alternative treatment Associated lesions are usually seen in those critical patients. Hemothorax may be present. The authors propose a combined treatment of endovascular repair for the aortic lesion and video-assisted thoracoscopy surgery (VATS) for the treatment of chest bleeding complications. METHODS: The authors report a series of three patients with post-traumatic aortic lesion and hemothorax. In two patients endovascular procedure was first performed, followed by VATS, few days later, for retained hemothorax. In the third patient the two procedures were performed at the same time because of the patient's critical conditions. RESULTS: There was technical success of stent-graft placement in all the treated cases. No postoperative mortality. No postoperative paraplegia. No VATS converted to thoracotomy. The postoperative follow-up time range between 10 and 19 months. CONCLUSION: Considering the relatively short procedural time and minimally invasive approach of both techniques, the concomitant use of them may represent an alternative to standard open surgery in cases of thoracic aorta lesions associated with hemothorax. Those procedures may be performed sequentially or together in emergency cases with intra-thoracic more active bleeding to exclude or to treat intra thoracic bleeding.     

Thoracoscopic application of a topical sealant for the management of persistent posttraumatic pneumothorax

BACKGROUND: Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of blunt or penetrating chest trauma. Currently, most patients are managed with pleural chest tube(s) and suction drainage. Prolonged hospital stay and added cost of care are not uncommon. METHODS: Over a 2-year period, 13 patients with PPP, nonresponsive to conventional management, underwent video-assisted thoracoscopic surgery (VATS). As part of our protocol for PPP, routine preoperative computed tomography of the chest and bronchoscopy to determine the presence of associated injuries were performed in all of the patients. During the VATS procedure, all of the patients underwent drainage of any retained hemothorax, and a topical surgical sealant was applied to the source of the air leak as definitive treatment. RESULTS: A persistent pneumothorax with an air leak was identified in all 13 of the patients. There were 10 patients with blunt and 3 patients with penetrating injuries, respectively. The mean age for the patients was 34 years (range, 13 to 64 years). Parenchymal lacerations were identified in all of the patients ranging in size from 0.5 to 3 cm. After the VATS procedure and application of the surgical sealant, 11 patients had the chest tubes removed within 24 hours of the procedure. In the other two patients, the chest tubes were removed within 48 hours. There was no recurrence of the pneumothorax in any of these patients. The mean length of hospital stay before VATS and the application of the surgical sealant was 6 days (range, 2-14 days). CONCLUSION: Early VATS and the use of a topical sealant in patients with PPP is a safe and effective alternative to the conventional management with prolonged thoracostomy chest tubes or an open thoracostomy. This alternative management, when used early in the appropriate patient, will decrease the length of hospital stay, cost of care, and unnecessary procedures.     

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma. METHODS: A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI. RESULTS: One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound. CONCLUSIONS: In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.     

Video-assisted thoracic surgical applications in thoracic trauma

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

Thoracoscopic evaluation and treatment of thoracic trauma

VATS has a diagnostic and therapeutic role in the treatment of patients with chest trauma, but the basic rule of safety over technology must be applied. It is an effective means for managing diaphragmatic injuries, hemothorax, empyemas, and persistent air leaks in selected hemodynamically stable patients. An overview of reported series (Table 1) demonstrates that VATS can be used successfully in the evaluation of patients with blunt and penetrating trauma. In appropriately selected cases, thoracoscopy can prove to be useful, with conversion to thoracotomy in only 10% of patients. Additional studies must be performed to determine any cost benefit compared with conventional therapy.     

Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest

BackgroundThe precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM).MethodsA ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated.ResultsA total of 212 patients (mean injury severity score = 24, Abbreviated Injury Score for Chest = 3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM.ConclusionsThoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.     

Hemothorax related to trauma

Management of hemothoraces related to trauma follows basic tenets well-respected by both trauma and cardiothoracic surgeons. In most, a nonoperative approach is adequate with a defined group of patients requiring only tube thoracostomy. It is only in a true minority of individuals that operative intervention is necessary. In blunt thoracic injuries, the underlying organ damage may be the more life-threatening process, not the presence or absence of a hemothorax. For both blunt and penetrating injuries, the presence of retained hemothorax is well-treated by early intervention with thoracoscopic techniques, shown to decrease hospital stay and costs. Controversial areas including the use of prophylactic antibiotics, sequence of operative intervention in patients with combined thoracoabdominal trauma, and the use of emergency department thoracotomy, remain a challenge but recent literature can serve to guide the clinician.     

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

: 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. : 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. : 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. : 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.     

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.     

Early evacuation of clotted hemothorax

Thoracotomy is infrequently required for penetrating or blunt thoracic trauma. Complications of thoracic trauma, such as clotted hemothorax and empyema, significantly increase morbidity, mortality, and length of hospitalization. Among approximately 9,000 patients with blunt or penetrating thoracic trauma seen during a recent eleven year period, 33 per cent (3,000 patients) presented with hemothorax or pneumohemothorax. The average length of hospitalization in the patient with uncomplicated thoracic trauma was less than six days. Among the 3,000 patients with hemothorax or pneumohemothorax, 2,600 (85 per cent) were treated with a drainage procedure. Among this group, clotted hemothorax or posttraumatic empyema developed in 85 (3.3 per cent). Among ten patients undergoing evacuation of a clotted hemothorax within five days of admission, there was zero mortality and an average hospital stay of ten days. Forty-one patients undergoing decortication more than five days after injury had a 2.4 per cent mortality, with the average period of hospitalization being twenty-five days. Thirty-four patients requiring decortication and drainage of empyema had a 12 per cent mortality and an average hospital stay of forty-one days. Among those patients in whom empyema developed, the most frequently associated injuries were enteric. These complications occurred due to inadequate evacuation of the original hemothorax, nonfunctioning tube thoracostomy, physician delay in recognition of the pathologic process, and bacterial contamination of the hemothorax. When complications secondary to tube thoracostomy dysfunction occurred, early operative evacuation of clotted hemothorax decreased the mortality, morbidity, and hospital stay and prevented the development of empyema.     

Diaphragmatic injuries.

OBJECTIVES: (1) To determine the actual incidence rate of blunt and penetrating diaphragmatic injuries (DI); (2) to evaluate the effectiveness of urgent surgical intervention for treatment of DI; and (3) to reveal main causes of postoperative complications. METHODS: We reviewed: (1) forensic medical examination charts of 3353 subjects, who died due to polytrauma (including injuries to the chest and/or abdomen) at accident sites; and (2) medical case reports of 4857 patients, treated for thoracoabdominal trauma (TAT) from 1962 to 1998. A detailed analysis was completed with 12 years (1987--1998) of clinical experience, involving 65 (43 penetrating, and 22 blunt) cases of DI. RESULTS: According to forensic medical data, blunt and penetrating DI occurred in 3.7% and 2.6% of individual cases, respectively. Among patients suffering from TAT, it was revealed that blunt DI had occurred in 1.1%, and penetrating in 3.9% of the cases. This data indicates if all the victims, who had sustained TAT, had survived, the incidence rate of DI would have been 2.6% (blunt -- 2.1%, and penetrating -- 3.4%). All the patients, provided surgical operations due to DI, survived. Morbidity in patients, suffering from blunt and penetrating DI, was 50%, and 35%, respectively. In the group of patients, suffering from penetrating DI, shock, intrapleural and/or intraabdominal haemorrhage, and liver injuries constituted a significant (P<0.05) influence, relevant to development of postoperative complications. The risk of complications was significantly (P<0.05) greater in cases of gunshot injuries. Fractures of chest bones, injuries of abdominal organs, and intraabdominal haemorrhage constituted a significant influence (P<0.05), relevant to development of complications after blunt DI. CONCLUSIONS: (1) The danger to the health or even life of patients is not directly caused by DI, but by consequential complications and associated injuries; (2) the effectiveness of treatment is determined by purposeful surgical diagnostics with particular regard to DI and urgent surgical intervention.     

Incidence and management of occult hemothoraces

BACKGROUND: Little is known about the incidence of and associated management outcomes of occult hemothorax in blunt trauma patients. The increased use of computed thoracic tomography for the evaluation of the multiply injured blunt trauma patient has led to an increase in the identification of these hemothoraces and management dilemmas. METHODS: A retrospective review of blunt trauma patients with occult hemothoraces was performed. Patients were divided into 2 groups: chest tube versus no chest tube. Outcomes and complications for the 2 groups were defined. Data included demographics, Injury Severity Score, length of stay, need for mechanical ventilation and thoracic consult, pneumonia, and empyema. The size of the occult hemothorax was measured on the computed thoracic tomography. RESULTS: Eighty-eight patients (21.4%) had a total of 107 occult hemothoraces. Patients in the chest tube group were more likely to have a higher Injury Severity Score and an associated occult pneumothorax and to have smaller hemothoraces. CONCLUSIONS: Occult pneumothoraces occur in a significant proportion of the multiply injured blunt trauma population. Small, isolated, occult hemothoraces can be managed safely in the stable patient.     

Early decortication after thoracic trauma

Twenty-three patients who sustained either blunt or penetrating thoracic trauma underwent early decortication after failure of chest tube drainage. Patients were divided into two groups: (1) ten with isolated chest injuries were compared with (2) 13 with chest trauma and other associated major injuries. Group 1 patients had earlier decortication (10.3 days), rapid recovery (home in 6.1 days), and little morbidity. Group 2 patients had later decortications (19.3 days), higher incidence of infected clot, yet were home in 9.8 days after thoracotomy. Early decortication is advocated as a safe and expedient means of dealing with the complications of traumatic pneumothorax and hemothorax.     

Role of early thoracoscopy for management of penetrating wounds of the chest

Most nonlife-threatening penetrating wounds of the chest (PWC) are treated with a chest tube alone. This may be inadequate because missed injuries, retained hemothorax, or foreign material may be difficult to address later. Early thoracoscopy should improve outcome. We conducted a retrospective review of 88 stable patients with PWC initially treated with a chest tube and had retained a hemothorax beyond 48 hours. Twenty-seven underwent an early video-assisted thoracoscopy (VATS). Fifty-five were observed, chest tubes were manipulated, or an additional one placed. The outcome was compared with the National Trauma Data Bank and controlled for Injury Severity Score. Early VATS reduced length of stay (4.3 vs 9.4 days), days in the intensive care unit (1.3 vs 3.2), and open thoracotomy (0 vs 7). A chest tube undertreats a nonlife-threatening PWC correctable by timely VATs.     

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.     

Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 +/- 14 days vs. 3.7 +/- 7.1 days, p = 0.003), longer intensive care stays (12.2 +/- 12.5 days vs. 4.1 +/- 7.5 days, p = 0.001), and longer periods of TT, (6.5 +/- 4.9 days vs. 5.2 +/- 4.5 days, p = 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.     

Early Management of Retained Hemothorax in Blunt Head and Chest Trauma

Background

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

Materials and methods

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

Result

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

Discussion

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

     

Videoassistierte thorakoskopische Chirurgie beim Thoraxtrauma

Video-assisted thoracoscopy (VATS) has a place in both diagnosis and treatment of blunt thoracic trauma. Thoracoscopy is indicated after trauma in the presence of intrathoracic hemorrhage, persisting pneumothorax, insufficiently drained hemothorax, chylothorax, and posttraumatic pleural empyema, and in some cases of diaphragmatic rupture and mediastinal injuries. The patient must be hemodynamically stable before VATS is performed, and it must also be possible to position the patient on one side and perform single-lung ventilation. It is absolutely mandatory to know what the contraindications to this procedure are and to take account of the general condition of the patient and the impact any other injuries might have. During the acute phase VATS allows surgical control of bleeding. In the case of lung injury a stapler can be used for resection, usually wedge resection. Evacuation of intrathoracic blood may prevent formation of pleural adhesions. For persistent pneumothorax pleurodesis is best performed by thoracoscopy. When VATS is performed after thoracic trauma there is a 2% complication rate, complications including transient hypoxemia, reversible cardiac arrhythmias, lung injury, bleeding in the chest wall, and intercostal neuralgia.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.