Eur J Cardiothorac Surg 2004;25:1048-1053
© 2004 Elsevier Science NL
Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries
A.V. Manlulu,
T.W. Lee,
K.H. Thung,
R. Wong,
A.P.C. Yim*
Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China
Received 17 December 2003;
received in revised form 12 February 2004;
accepted 16 February 2004.
* Corresponding author. Tel.: +852-2632-2629; fax: +852-2647-8273
e-mail: yimap{at}cuhk.edu.hk
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Abstract
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Objective: Thoracic injuries are among the most severe forms of trauma and also a leading cause of morbidity and mortality. Video Assisted Thoracic Surgery (VATS) has recently provided an alternative method to simultaneously diagnose and manage patients sustaining chest injuries. We analyze our experience with VATS in the setting of thoracic trauma detailing indications for exploration, procedures performed and results of surgery. Methods: A 6-year single institution review of patients undergoing VATS due to injuries sustained from both blunt and penetrating chest trauma at a Level I trauma center and university teaching hospital. Comparisons were made between groups of blunt and penetrating trauma as to Injury Severity Score (ISS), presence of extra-thoracic injuries, initial thoracostomy drainage and length of postoperative stay. Results: VATS was successfully performed in 19 consecutive patients without conversion to thoracotomy. Indications for exploration included acute hemorrhage, retained hemothorax, suspected diaphragmatic injuries (DI), suspected cardiac injury, intra-thoracic foreign body, persistent airleak and chronic empyema. Procedures performed consisted of evacuation of retained hemothorax, hemostasis of intra-thoracic bleeders, repair of DI, wedge lung resections and decortication. Mean postoperative length of stay was 5.86 days. There were no morbidities. One patient with severe intra-abdominal injuries expired on the first postoperative day. Conclusion: In hemodynamically stable patients with thoracic injuries, VATS provides an accurate assessment of intra-thoracic organ injury and can be utilized to definitively and effectively manage injuries sustained as a result of blunt or penetrating thoracic trauma. VATS should be used with caution in patients sustaining severe and life threatening intra-abdominal injuries.
Key Words: Video assisted thoracic surgery • Thoracic Trauma
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1. Introduction
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Trauma is a leading cause of morbidity and mortality in industrialized nations. In the United States, trauma associated deaths outnumbers all other diseases combined in individuals aged 1–34 years and remains the leading cause of mortality in persons up to 44 years of age. Thoracic injuries in particular account for approximately 25% of trauma associated deaths and an estimated one third of these mortalities occur immediately due to the severe nature of injuries sustained [1]. Although the majority of hemodynamically stable patients with thoracic injuries can initially be managed with tube thoracostomy and close observation, some patients may progress to develop acute and chronic complications requiring operative therapy. In the past, most patients necessitating operative intervention secondary to chest trauma would be subjected to an open thoracotomy incision, which has been labeled as the most morbid of surgical incisions further compounding the physiologic stress response to the injury itself. This provided the impetus for a less invasive method to diagnose and treat thoracic injuries paving the way for thoracoscopy, which was originally employed in the trauma setting by Branco in 1943 [2]. The original technique of thoracoscopy was described as cumbersome and allowed limited visualization of the intra-thoracic anatomy. Since its inception, rapid progress and advancement in technology, endoscopic instrumentation as well as anesthetic techniques have revolutionized thoracic surgery and ushered in the era of video assisted thoracic surgery (VATS). The application of this new technique in trauma was originally reported in a series evaluating diaphragmatic injuries [3]. In addition to detecting diaphragmatic injuries, numerous other indications have evolved as a result of increasing familiarity and acceptance of the VATS technique worldwide. In this study, we conducted a retrospective review of VATS in the setting of thoracic trauma at our institution describing characteristics of injury, indications for intervention, procedures performed and outcome in terms of postoperative length of stay, morbidity and mortality.
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2. Patients and methods
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A retrospective series from the period July 1996 to September 2002 to include patients in which VATS was performed for thoracic trauma. Videothoracoscopy performed as a result of iatrogenic injuries were excluded. The study was conducted at the Prince of Wales Hospital, a Level I trauma center, tertiary referral center for the New Territories region and the teaching hospital of The Chinese University of Hong Kong. Several patients were initially treated by outlying district hospitals and subsequently transferred for further care. Patients were categorized into blunt or penetrating groups based upon the mechanism of injury. Initial assessment, resuscitation and stabilization were carried out in the Emergency Department by a multidisciplinary trauma team. All patients had a baseline chest X-ray, further imaging modalities were carried out if the patient was in stable condition. A CT thorax was requested if there was suspicion of great vessel/vascular injury and a transthoracic echo was performed if cardiac injury was suspected based on physical examination or location of wounds in proximity to the heart. Chest tubes were inserted based on clinical or radiologic evidence of pneumohemothorax with initial drainage and subsequent output used as a guide in determining the need for further intervention. Referrals were made to other specialties for further assessment and treatment of extra-thoracic injuries when present. Patients were considered for VATS if they were hemodynamically stable and there was an indication for exploration based on evidence of acute hemorrhage (initial thoracostomy drainage >1000 ml), pleural space collection/infection as demonstrated on radiologic studies, suspected intra-thoracic organ injury based on location and characteristic of wounds, recurrent pneumothorax or intra-thoracic foreign body seen on radiologic exam. A thoracoscopic approach was not considered if any one of the following were present: persistent hemodynamic instability, evidence of cardiac or great vessel injury, evidence of major tracheobronchial injury or inability to tolerate single lung ventilation. Patients requiring another operative procedure in the same setting for extra-thoracic injuries in addition to VATS were not excluded from analysis. Prioritization of surgical approach was given to life threatening injuries, other less urgent injuires were addressed at a later date when the patient's status stabilized. Prophylactic antibiotic was administered upon induction of anesthesia and continued for 2 doses or longer if infection/contamination was suspected. All videothoracoscopic procedures utilized selective single lung ventilation and standard intraoperative monitoring with the patient placed in the full lateral decubitus position. VATS was performed using a 3-port technique utilizing when possible an existing thoracostomy tube site. Intensive care unit (ICU) transfer was arranged if close monitoring and postoperative ventilatory support was required otherwise, patients were placed in a regular ward. Discharged patients were followed up at the Outpatient Department where history and physical examination with particular emphasis on the injuries sustained were performed and chest radiograph on the day of appointment was evaluated. The Injury Severity Score (ISS) was retrospectively derived based upon clinical, radiologic and intraoperative findings. Patient demographics, mechanism of injury, presence and type of extra-thoracic injuries, time from injury to operation, postoperative length of stay, morbidity, mortality and length of follow up were retrieved from hospital records. The Mann–Whitney U-test was used to compute for significance between blunt and penetrating injuries using the variables of ISS, presence/absence of extra-thoracic injuries, initial thoracostomy output and postoperative hospital stay. P-value of less then 0.05 was considered statistically significant.
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3. Results
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A total of 42 patients underwent surgery for thoracic trauma related injuries with VATS employed in 19 consecutive patients (45.23%). None of the patients in which VATS was performed required conversion to open thoracotomy. The patient mean age was 37.95 years (range 14–64 years) with 16 males (84.21%) and 3 females (15.78%). According to mechanism of injury, there were 11 patients (57.89%) sustaining penetrating injuries as opposed to 8 patients (42.10%) with blunt injuries. There were no gunshot-associated injuries; all penetrating injuries were the result of stab wounds with 7 left sided chest injuries (63.63%) and 4 right-sided chest injuries (36.36%). Overall, under half of the patients (N=9, 47.37%) sustained extra-thoracic injuries. The most common site of associated injury was skeletal (spine/extremity) and intra-abdominal in 4 cases each, skin/soft tissue in 3cases and neurologic (cranial) in 2 cases. In patients with blunt chest trauma, the majority of cases (5 patients, 62.5%) were diagnosed to have other associated injuries whereas only 4 patients (36.36%) with penetrating chest trauma sustained extra-thoracic injuries (P=0.273, NS). The mean ISS for both blunt and penetrating cases was 14.57 (range 4–50). Mean ISS in patients with penetrating injuries was 10.90 (range 9–18) compared to 18.25 (range 4–50) for blunt injuries (P=0.371, NS). Sixteen patients received tube thoracostomy prior to VATS. Mean initial tube thoracostomy drainage was 814 ml (range 40–1600 ml), 541.11 ml (range 150–1070 ml) for penetrating against 1048.57 ml (range 40–1600 ml) for blunt injuries (P=0.072, NS). Several patients presented with either circulatory shock or developed hypotension, a stable hemodynamic status following fluid resuscitation was a factor in deciding to proceed with VATS. Indications for exploration were acute hemorrhage in 6 patients, retained hemothorax in 6 patients, suspected diaphragmatic injury in 3 patients, suspected cardiac injury (chest wall defect with visible pericardial sac, 2D Echo negative for effusion), intra-thoracic metallic foreign body (detected on chest X-ray), recurrent pneumothorax and chronic empyema in 1 patient each respectively. Median time from injury to operation in all groups was less then 1 day, being 2.50 days for blunt trauma and less than 1 day for penetrating trauma. Concomitant surgical repair of extra-thoracic injuries was carried out in a total of 8 patients (42.10%) sustaining both blunt/penetrating traumas (3 blunt, 5 penetrating). Procedures performed included evacuation of retained hemothorax/hemostasis in 13 cases, wedge lung resection (2 bleeding parenchymal lacerations, 1 intraparenchymal metallic foreign body) in 3 cases, decortication (1 chronic empyema, 1 loculated hemothorax) in 2 cases and repair of diaphragmatic laceration in 2 cases (Table 1). There was no significant difference with regard to postoperative length of stay between the blunt (mean 7 days) and penetrating trauma (mean 4.72 days) groups (P=0.435). Three patients (2 blunt, 1 penetrating) required ICU admission for ventilatory support postoperatively, these patients had a mean ISS of 30 and stayed 1–2 days in intensive care. The mean follow up was 16.59 weeks. There were no morbidities nor reoperative procedures during hospitalization and on follow up. One patient with blunt thoracoabdominal injuries underwent both thoracic and abdominal explorations in a single setting. VAT exploration revealed bleeding from the intercostal vessels and a subsequent laparotomy during the same setting showed a perforated colon, left renal pedicle injury with a large retroperitoneal hematoma and fractures of lumbar spine 2–3. This patient expired in the ICU due to multiple organ failure on the first postoperative day.
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4. Discussion
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Before the advent of minimal access thoracic procedures, surgery for thoracic trauma or failure of tube thoracostomy management would often require an open thoracotomy. Recently, VATS has provided the surgeon with an alternative method for the accurate and direct evaluation of the chest wall, lung parenchyma, mediastinum and diaphragm with the advantage of simultaneously allowing definitive treatment of such injuries. Despite the reported accuracy of VATS in the evaluation of chest trauma and the effectiveness of this technique to successfully treat or repair a variety of injuries, its application in thoracic trauma is still not well defined. This article analyzes our experience with VATS in the setting of thoracic trauma. The reported conversion rates to an open procedure for videothoracoscopy in blunt and penetrating chest injuries ranges from 13.8–31% [4–6], we however managed to treat a variety of thoracic injuries utilizing VATS exclusively. Different factors have been identified which increase the rate of conversion to an open procedure. A study by Sosa and colleagues concluded that the mechanism of injury resulted in differing rates of conversion with gunshot injuries having the lowest conversion rate (9%) and stab wounds necessitating the highest rate of thoracotomy (20%) [4]. The specific site of injury also plays an important role as outlined in a study by Pons et al., where they reported a 31% conversion rate for precordial penetrating injuries mainly due to the associated cardiac injuries [5]. The majority of patients required placement of tube thoracostomies prior to VATS, the character and amount of drainage served as one of the guidelines in determining the need for further intervention (Fig. 1)
. However, tube thoracostomy is not an innocuous procedure and may even contribute to morbidity and extended hospitalization by potentially introducing microorganisms into the pleural cavity or incomplete evacuation of clotted blood. In a review of thoracic trauma cases treated by tube thoracostomy, Helling and associates reported that 3% developed empyema, 18% of patients had retained hemothorax, and 24% developed recurrent pneumothorax with an overall complication rate of 36% [7]. Compared to a tube thoracostomy, a randomized controlled trial conducted by Meyer et al. in patients with traumatic retained hemothoraces demonstrated that VATS shortened duration of chest tube drainage, length of stay and hospital costs [8]. In addition, they also reported that in patients who fail initial tube thoracostomy, outcomes were similar in patients randomized to either VATS or thoracotomy. Timing of surgery is also an important consideration in retained hemothoraces as mortality and conversion to thoracotomy increase proportionally from the elapsed time of injury due to complications from fibrothorax and empyema. Therefore, it has been recommended that surgery be accomplished within 5 days from injury [9]. In our series, 1 patient presented with retained hemothorax 90 days post injury and another with empyema 21 days after sustaining trauma. In both cases, despite the presence of dense adhesions and a thick peel, successful evacuation and lung expansion were achieved using a VATS approach. By convention, initial chest tube output of greater then 1000 ml or continued hemorrhage of 200 ml/h or more for 3 h serve as indicators for surgical exploration to identify and control the source of bleeding which most commonly arises from the intercostals vessels or lung lacerations. These types of injuries are amenable to videothoracoscopic control via diathermy or suture ligation for bleeding intercostals vessels and suturing or stapled lung resection for bleeding parenchymal lacerations. Massive hemorrhage served as the one of the most common indication for surgery in this series. Mean thoracostomy drainage was noted to be higher in patients sustaining blunt trauma and this may be a reflection of the more severe force of injury incurred. Complete evacuation of blood in the thoracic cavity and meticulous hemostasis is of paramount importance in preventing future complications of fibrothorax and empyema. Both situations make VATS more difficult and technically demanding thereby increasing risk of conversion to thoracotomy, morbidity, mortality and prolonging hospital stay. VATS allows the thoracic cavity to be completely explored and other possible sites of bleeding such as from the heart or great vessels can be identified. The value of VATS in patients with possible penetrating cardiac wounds was analyzed in a recent study by Pons et al. where they concluded that videothoracoscopy can be used to detect cardiac injuries, however, thoracotomy was still recommended for definitive repair [5]. The lone mortality in this series occurred in a patient with severe combined thoracoabdominal injuries (ISS of 50), the thorax was explored initially due to acute massive hemorrhage (1400 ml) however, the patient developed subsequent hypotension intraoperatively and underwent combined exploratory laparotomy. Interestingly, none of the studies enrolled patients requiring combined emergency VATS and abdominal operations for thoracoabdominal trauma. In fact, multiply injured patients requiring emergent combined thoracic and abdominal exploration were specifically used as exclusion criteria for VATS in several studies [6,8,10]. In an effort to clarify dilemmas associated with thoracoabdominal injuries, Asensio et al. in a study of 254 patients with penetrating injuries (mean ISS 27) revealed that patients requiring combined procedures had an inherently high mortality (59%) and chest tube output can be a misleading indicator to explore the thoracic cavity first [11]. Four patients were diagnosed intra-operatively to have diaphragmatic injuries (DI), 3 of which necessitated repair. A transabdominal approach was utilized in 1 patient due to an associated splenic injury, the other 2 cases was successfully repaired thoracoscopically. Diaphragmatic injuries following abdominal or chest trauma have been reported to occur in 3% of cases. The difficulty in diagnosis lies in the fact that non-operative methods such as chest radiography, computed tomography and diagnostic peritoneal lavage may miss up to 30% of injuries. Missed DI are a potential source of increased morbidity and mortality due to the possibility of bowel incarceration/strangulation and more importantly because of the frequency of associated intra-abdominal or intra-thoracic injuries. VATS has been found to be the most accurate method (accuracy rate 98%) in diagnosing DI and unlike laparoscopy, does not require gas insufflation which may lead to the formation of a tension pneumothorax. One patient in our series had a metallic foreign body lodged in the lung sustained during penetrating trauma and was successfully recovered via a parenchymal wedge resection containing the foreign body. This illustrates yet another versatile application of VATS, allowing the expeditious removal of an intra-thoracic foreign body in a less invasive manner which would otherwise have required thoracotomy. A single patient with multiple rib fractures after sustaining blunt chest trauma developed a recurrent pneumothorax after chest tube removal and was discovered to have a parenchymal laceration that was managed with stapled wedge resection. The management of persistent airleak following thoracic trauma is similar in many aspects to those with spontaneous pneumothorax. Once the site of airleak has been identified, it can be controlled with either endoscopic stapling/suturing and the option of pleurodesis may be considered. A prospective evaluation of VATS for persistent airleak due to trauma conducted by Schermer and colleagues showed a reduction in the number of chest tube days and length of stay as opposed to nonoperative treatment [12]. Lung-sparing resections in trauma have been associated with improved outcomes. A review of 143 lung resections following traumatic injury found that mortality rate increased with major lung resection and that blunt injuries have a higher mortality primarily due to extra-thoracic injuries [13]. In our series, wedge lung resection using endoscopic staplers was performed in 3 cases, this method was favored over suture repair primarily because it can be performed more expeditiously. No morbidities were observed in this series and this is consistent with the overall low complication rates associated with VATS. A meta-analysis of thoracoscopy in trauma involving 28 studies and more than 500 patients revealed a 2% complication rate and 0.8% missed injury rate with a benefit of preventing 62% of patients from having a thoracotomy or laparotomy [14]. In conclusion, VATS is an accurate and effective modality in the evaluation and management of hemodynamically stable thoracic injuries. It can be successfully applied in cases involving acute and chronic sequelae of hemothorax, suspected intra-thoracic bleeding or injury, retrieval of foreign bodies, repair of diaphragmatic injury and recurrent pneumothorax. However, caution should be exercised in the multiply injured patient with severe intra-abdominal injuries.
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Abstract
1. Introduction
