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Роль видео-ассистированной торакальной хирургии в диагностике и лечении торакальных повреждений
Role of video-assisted thoracic surgery in the evaluation and management of thoracic injuries
Department of Thoracic Surgery, General Hospital of Attica «KAT», 2 Nikis Street, 145 61 Kifissia, Greece
Received 28 January 2005; received in revised form 13 March 2005; accepted 14 March 2005
*Corresponding author. Tel.: +30? fax: +30?.
The aim of this study was to evaluate the experience of ourinstitution with the use of video-assisted thoracic surgery(VATS) in chest trauma. Between January 1999 and September 2004,25,213 patients presented with chest trauma to the emergencyroom, and 2304 were admitted to our service. Twenty-three hemodynamicallystable patients (1%) underwent VATS. They were 19 men and 4women with an average age of 42 years (range, 19㫛 years).Indications included post-traumatic hemothorax in 11 patients,and post-traumatic empyema in 3, treated after 24 h oftrauma. Indications for exploratory VATS in the acute phaseincluded suspected diaphragmatic injury in 3 patients, persistentpneumothorax in 2, continued hemorrhage in 2 and removal ofintrathoracic foreign body in 2. There was no mortality andcomplications occurred in 3 patients (13%). Management of hemodynamicallystable thoracic injuries by using VATS provides diagnostic accuracyand therapeutic efficacy. It can be successfully applied inthe trauma setting and surgeons should gain experience withits use.
Key Words: VATS; Chest trauma; Thoracic
Thoracic trauma accounts for 25% of trauma associated deathsand contributes significantly in another 25% of deaths relatedto trauma. The majority of patients with thoracic injuries areinitially treated with tube thoracostomy and observation. Approximately10㪬% of patients who sustain chest trauma will eventuallyneed thoracotomy [1,2]. Thoracoscopy as a method of explorationin penetrating thoracic injuries was originally reported byBranco in 1946. In the early 1990s, with the evolution of minimallyinvasive surgery and video technology, VATS was introduced inthe trauma setting, in a series evaluating diaphragmatic injuries.
The aim of this study was to review the experience obtainedat our institution with the use of VATS in the evaluation andmanagement of thoracic injuries.
The study was conducted at the KAT General Hospitalof Attica, which is the busiest Level I trauma center of ourcountry. Between January 1999 and September 2004, 25,213 patientswith chest trauma were presented in the Emergency Department(ED) and 2304 of them were admitted to our service. Twenty-threehemodynamically stable patients (1%) underwent VATS for diagnosisor treatment of thoracic injuries. We analyzed their medicalrecords regarding age, sex, clinical presentation, mechanismof injury, injury severity score (ISS), indications for VATSprocedures, morbidity, mortality and length of hospital stay.
All patients were assessed and stabilized by the trauma teamof our hospital upon arrival in the ED. Apart from the baselinechest X-ray all 23 patients underwent a CT chest scan in orderto rule out cardiovascular injury. They also underwent tubethoracostomy depending on the clinical or radiologic evidenceof pneumothorax or hemothorax. Referrals were made to otherspecialties for assessment and management of extra-thoracicinjuries and further radiologic or laboratory studies were carriedout accordingly.
Following a complete clinical and laboratory assessment in theED, patients were considered for VATS if they were hemodynamicallystable, there was an indication for exploration and no contraindicationto VATS for trauma [2,4]. With regard to indications for VATSwithin 24 h of trauma we excluded patients requiring laparotomyor other surgical procedure for extra-thoracic injuries, becausethey were considered unstable.
During the study period 112 patients underwent emergency thoracotomyfor blunt or penetrating thoracic trauma with VATS employedin 19 men and 4 women with an average age of 42 years (range,19㫛 years).
We sorted out two groups of patients: group I consisted of 9patients treated within 24 h of trauma; group II comprised14 patients treated 5 to 21 days following their injury.
All 9 patients were males in group I; in 6 patients penetratingtrauma (PT) resulted from stab wounds while in one it resultedfrom a shot-gun. Three patients sustained blunt trauma (BT)following a traffic accident. Indications for exploratory VATSincluded not major but continued haemorrhage (<200 ml/h),lasting more than 3 h (with initial chest tube output <500 ml),in 2 hemodynamically stable patients, persistent air leak andpneumothorax following a stab wound in the Boxarea in 2, after an observation period of 24 h (intra-operativebronchoscopy had ruled out tracheobronchial injury), suspecteddiaphragmatic injury (DI) in 3, and removal of intra-thoracicforeign body in 2. Procedures included evacuation of hemothoraxin all patients, coagulation of bleeding intercostal vesselsin 3, stapled lung resection in 4, removal of foreign bodies(lead shot and rib fragment) in 2, and suture repair of a smalldiaphragmatic laceration (2 cm) in one. Inspection fordiaphragmatic laceration was negative in 1 patient. The procedurewas converted to open thoracotomy in one patient with BT whosustained a large rupture (6 cm) of the right hemi-diaphragm.He also sustained brain and liver contusion but he had a negativefor intra-peritoneal bleeding diagnostic peritoneal lavage (DPL).All patients in group I had a negative for cardiovascular injuryspiral CT scan of the chest and either a negative CT scan ofthe abdomen or a negative, for intra-peritoneal bleeding, DPL.Only the patient with the removed bone fragment developed apostoperative complication (pneumonia) that was treated conservatively.
Group II comprised 11 patients who presented with a posttraumatichemothorax and 3 with a posttraumatic empyema that were treatedwith VATS after 24 h of trauma. Nine of these patientssustained BT while 5 suffered PT. Extra-thoracic injuries wereobserved in 6 out of these 9 patients with BT and included braincontusion in 3, liver contusion in 2, long bone fractures in2, and spleen rupture (requiring splenectomy) in 2. Posttraumatichemothorax or empyema was diagnosed within 5 to 21 days(average 11 days), following the initial injury. All patientshad undergone tube thoracostomy, and they became symptomaticfollowing its removal. The decision to proceed with VATS explorationwas based on the time elapsed (suspected fibropurulent stage),and the clinical or radiologic findings (loculations). Debridementand deloculation of the clotted hemothorax or the empyema usingVATS was rewarding in 9 patients with clotted hemothorax andin 2 with posttraumatic empyema. Decortication of the lung viathoracotomy was necessary in 2 patients with hemothorax andin one with empyema, because of a thick peel preventing lungre-expansion. It is worthy to mention that they were diagnosed15, 18, and 21 days after their injury. Complications occurredin 2 patients and included pneumonia and postoperative bleeding,both treated conservatively with success.
Looking at both groups together, mean ISS in patients with PTwas 13 (range, 9㪱) as compared with 32 (range, 16㫊)for patients with BT. There was no procedure related or hospitalmortality and the morbidity was 13% (complications were observedin 3 out of the 23 patients). VATS procedures were convertedto open thoracotomies in 4 out of the 23 patients (17%). Theaverage postoperative hospital stay was 7.6 days (range,4㪧 days).
Although the use of VATS in the management of most of the thoracicdiseases has gained wide acceptance, its role in the settingof thoracic trauma is not well established.
As regards the efficiency of VATS in the management of thoracictrauma, Manlulu et al. managed to treat 19 patients with sustainedchest injuries by using VATS exclusively, and without the needto convert to an open procedure . In our series, 17% of thepatients necessitated thoracotomy (one for repair of a diaphragmaticrupture and three for decortication). As Lang-Lazdunski et al.recommended, only surgeons with extensive experience in VATSshould use it in trauma, and great prudence is required in somecases (for example when removing a clot), because the need forimmediate conversion to thoracotomy might emerge. They had a24% conversion rate .
In hemodynamically stable patients with traumatic hemothoraxand continued bleeding, having excluded cardiovascular injury,the commonest causes of bleeding are the intercostal vesselsor lung lacerations which are both amenable to videothoracoscopiccontrol via diathermy, clips or staplers [3ס]. In ourseries, two stable patients with BT and PT, one each, presentedwith ongoing but not significant bleeding, had a successfulevacuation of their hemothoraces with coagulation of their bleeders,and were spared thoracotomy. The use of VATS proved safe andefficient in the evaluation of two other patients with PT inthe Box area, which is defined between the midclavicularlines (medially of the nipples), in front, and between the scapulaeon the back. Mediastinal injuries were ruled out and a successfulstapling of small but deep pulmonary lacerations was performedavoiding thoracotomy. Many authors have found VATS useful inthe management of air leaks and traumatic pneumothoraces, acceleratingpatients recovery (particularly those intubated), reducinghospital stay and morbidity, and restricting the number of thoracotomies[3ס].
In regards to DI, which is observed in 1ף% of the casesafter BT and in 10㪧% after PT, the diagnosis is missedin 12㫚% of these injuries using the common diagnosticmodalities (chest X-ray, CT chest and DPL), and there is evena 30% rate of false negative for DI laparotomies in cases ofpenetrating thoracoabdominal trauma [4,6,7]. In the largestpublished series of patients undergoing VATS to exclude a DIafter PT, Freeman et al. concluded that VATS is a safe techniquethat can rapidly assess the diaphragm . We also found VATSadvantageous in identifying or excluding DI in 3 patients andin repairing a small DI in one of them.
The application of VATS was also effective and versatile inthe removal of intrathoracic foreign bodies in two patientswith BT (rib fragment), and PT (lead shot), one each, that otherwisewould have needed thoracotomy. Similarly, other investigatorsagree that VATS should not be an argument to remove intrathoracicforeign bodies even in asymptomatic patients, after chest trauma[3,4].
The traditional initial treatment for patients with post-traumatichemothoraces or empyemas is chest tube drainage. Placement oftube thoracostomy in trauma patients is reported to be associatedwith a 36% overall complication rate, including empyema in 3%,retained hemothorax in 18% and recurrent pneumothorax in 24%. The use of intra-pleural fibrinolysis in the resolutionof clotted hemothoraces is reported to be associated with anoverall success rate of 92% and it is recommended by some authorsas an alternative to surgery . We have no such experiencein our hospital. In a controlled randomized trial, Meyer etal. compared patients who sustained traumatic hemothoraces treatedonly with additional tube thoracostomy with patients treatedwith early VATS. They demonstrated that intent to treat earlywith VATS decreased duration of chest tube drainage, lengthof hospitalization and hospital costs . We managed to treatsuccessfully 9 patients with clotted hemothorax and 2 with empyema.We believe that time elapsed from trauma is important and wehave a low threshold for converting to thoracotomy when thelung is entrapped during VATS.
In conclusion, VATS for specific indications in chest traumais associated with improved outcomes, decreased morbidity andmortality, and shortened hospital stay. It can be successfullyapplied in the acute and chronic phase of hemodynamically stablethoracic injuries. It provides diagnostic and therapeutic benefitsand thoracic surgeons should be encouraged to incorporate itinto their armamentarium and gain experience with its use.
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