EarlyEvacuation of Posttraumatic Clotted Hemothorax or Retained Pleural Fluid: Results of VATS Versus Conventional Thoracotomy
Alaa Gafar MD, Mohamed Khairy MD, Yousry El-Saied MD, Yousry Shaheen, MD, Mahmoud El-Elmam MD, Ahmed Ali MD.
Department of Cardiothoracic Surgery, Benha Faculty of Medicine,
Benha University, Egypt
Abstract
Objective:To compare the outcome of VATS versus conventional thoracotomy in the early evacuation of posttraumatic clotted hemaothorax or retained pleural fluid in patients with chest trauma after failure of the initial management with tube thoracostomy.
Patients and methods: Between January 2001 and December 2005, fifty-four patients with posttraumatic clotted hemothorax or retained pleural fluid were included in this study.They were claimed to have clotted hemothorax or retained pleural fluid after 3 to 5 days posttruama by chest roentgenogram and chest CT. The patients were divided into 2 groups, group I (VATS group) and group II (thoracotomy group). Group I patients (VATS group) included 23 patients, VATS was performed for evacuation of posttraumatic clotted hemaothorax or retained pleural fluid. Group II patients (thoracotomy group) included 31 patients; conventional thoracotomy was performed for management of posttraumatic clotted hemothorax.
Results:There was no statistical significant difference between the mean ages of both groups, as the mean age of the VATS group patients was 33 ± 8 years, while it was 32.7 ± 7 years for the thoracotomy group patients. The mean preoperative ICT period was (6 ± 1.5 days VS 7 ± 2 days respectively). It was statistically non-significant. There was statistical significant difference (P-value ≤ 0.05) between the VATS group patients and the thoracotomy group patients in the mean operative time (70 ± 4 minutes VS 77 ± 6 minutes respectively), and, mean volume of analgesics given in the first 24 hours postoperatively (201 ± 17 mg VS 239 ± 18 mg respectively), in the mean ICT drainage in the first 24 hours postoperatively (219 ± 22 ml VS 230 ± 18 ml respectively), and, mean ICT period postoperatively (4 ± 1 days VS 6.5 ± 1 days respectively).There was also statistical significant difference between the 2 groups of patients in the mean hospital stay postoperatively (6 ± 3 days VS 10 ± 2.5 days respectively), and, the mean period to return to more or less normal activity (15 ± 1.8 days VS 23 ± 3.5 days respectively). Complications occurred less in VATS group of patients than that of thoracotomy group of patients. Prolonged air leak (13% VS 20%, respectively), postoperative empyema (4% VS 10%, respectively) and wound infection (0% VS 10%, respectively). Reoperation for management of postoperative empyema performed in one patient (4%) of the VATS group of patients and 2 patients (6%) of the thoracotomy group of patients
Conclusion: we concluded thatearly thoracoscopic intervention should be considered for management of posttraumatic clotted hemothorax or retained pleural fluid. Benefits include abbreviated thoracostomy tube drainage, shorter hospital stay after procedure, shorter overall hospitalization, as well as early return to normal activity. Moreover, early evacuation usually decrease the complications associated with retained hemothoraces, such as empyema and fibrothorax. Also, thoracoscopic surgery has fewer complications than the conventional thoracotomy
Introduction:
Thoracic trauma accounts for 25% of trauma associated deaths and contributes significantly in another 25 % of deaths related to trauma. The majority of patients with thoracic injuries are initially treated with tube thoracostomy and observation to deal with hemothorax or/and pneumothorax (Potris et al, 2005).The majority of chest trauma does not require major operations and tube thoracostomy remains the basis of treatment, but, failure to evacuate blood from the pleural space after thoracic trauma often results in extended hospitalization and complications, including empyema and fibrothorax, when thoracostomy tube placement fails, previous strategies to circumvent these complications have included placement of additional thoracostomy tubes or early thoracotomy (Meyer et al, 1997)and (Lazedunski et al, 1997).Open thoracotomy is a major surgical procedure which carries the high risk of mortality and morbidity. The operative incision by itself carries a prolonged recovery period even in cases with mild intrathoracic injury. The reported incidence of chronic postthoracotomy pain syndrome is 5% to 25% (Perttunem et al, 1999)and (Meyer et al, 1997).Video- assisted thoracoscopic surgery (VATS) has emerged as an alternative surgical technique in the evaluation and early treatment of posttraumatic pleural complications. Notably, retained hemothoraces have been successfully evacuated and currently indicated as one of the most suitable conditions amenable to thoracoscopic surgery (Navsaria et al, 2004).
The aim of this study is to compare the outcome of VATS versus conventional thoracotomy in the early evacuation of posttraumatic clotted hemaothorax or retained pleural fluid in patients with chest trauma after failure of the initial management with tube thoracostomy.
Patients and Methods:
A total of 54 patients with posttraumatic clotted hemothorax or retained pleural fluid were included in this study. This study was carried out from January 2001 till December 2005. All thepatients were victims of blunt or penetrating chest trauma. They were diagnosed to have hemothorax or hemopneumothorax. All the patients were managed initially with tube thoracostomies to evacuate hemothorax or hemopneumothorax. They were claimed to have clotted hemothorax or retained pleural fluid, if 3 to 5 days posttruama, the chest roentgenogram showed persistent opacity which indicated residual clots or retained pleural fluid could be lager than 500 ml or this opacity occupied at least one third of the involved hemithorax. In all patients, CT of the chest was done to confirm the diagnosis, to localize the site of loculations, to evaluate the number of loculations, the presence or absence of thick pleural peels on the lung, and the condition of the lung whether it was entrapped or not entrapped. The patients included in this study if they were hemodynamically stable, had one or 2 accessible (by VATS) loculations and had no or thin pleural peels on the entrapped lung. The patients who were hemodynamically unstable, having multiple inaccessible (by VATS) loculations, having dense pleural thickening or those who were proved to have empyema preoperatively were excluded from this study.
The patients were divided into 2 groups, group I (VATS group) and group II (thoracotomy group). Group I patients (VATS group) included 26 patients with chest trauma who were managed initially with tube thoracostomy and claimed to have clotted hemothorax or retained pleural fluid, they were admitted and managed by VATS at the first 6 months of each year of the study. Unfortunately, three patients of those 26 patients were failed to be managed with VATS due to dense pleural adhesions which discovered intraoperatively, the decision was to convert the VATS procedure to the conventional posterolateral thoracotomy. So, the VATS group included only 23 patients. Group II patients (thoracotomy group) included at first 28 patientswith chest trauma who were managed initially with tube thoracostomy and claimed to have clotted hemothorax or retained pleural fluid, they were admitted and managed by thoracotomy at the last 6 months of each year of the study. The 3 patients with failed VATS procedure were added to this group, so the thoracotomy group included 31 patients.
Preoperative investigations included chest roentgenogram, CT of the chest and other routine laboratory investigations. Perioperatively, all patients were administered IV broadspectrum antibiotics. These antibiotics were continued postoperatively till the results of culture and sensitivity tests of the taken specimens were obtained, and then continue with the specific antibiotics.
Technique of VATS Procedure:
In the operating room, all the patients underwent general anesthesia with double lumen endotracheal intubation. Patients were placed in the corresponding full lateral decubitus position to facilitate conversion to a posterolateral thoracotomy if required. A two-cm incision was placed directly over the site of the loculated collection as determined by the CT scan or lateral chest roentgenogram. A suction catheter was introduced into the pleural cavity, into the loculated collection, and as much of the pleural fluid removed with a standard suction instrument or a suction/irrigator system. Pleural fluid was sent for microbiologic assessment as well as culture and sensitivity tests. Then, a 10-mm trocar was introduced through this small 2 cm incision with insertion of a “0” degree videothoracoscope camera into the loculated cavity. Another 2-cm incision was placed 8-10 cm away from the initial incision, along the same intercostal space, through which the suction catheter was introduced. Further evacuation of the pleural contents was performed under direct vision with the camera. Ring forceps was introduced to remove rind from the visceral and parietal pleura. Gentle dissection under direct vision with spong sticks and ring forceps released the trapped lung. So, the procedure was performed from within the loculated collection, gently releasing the adherent lung from the chest wall towards the normal lung.
Another one or two small incisions for introduction of other ports may be needed in the same intercostal space or another space, according to the evaluation of the pleural cavity and the site of the loculations by the camera, to evacuate and dealing with the retained pleural fluid. Once all the pleural fluid and fibrin was evacuated, adequate lung expansion was observed by ventilating the ipsilateral lung. Two wide bore thoracostomy tubes were introduced into the 1st two port sites, one into the previous loculated cavity and the other directed towards the apex. Closure of the other port or ports if present was done.
Technique of Thoracotomy Procedure:
In the operating room, all the patients underwent general anesthesia with single lumen endotracheal intubation. Patients were placed in the corresponding full lateral decubitus position. A limited posterolateral thoracotomy was made through the fifth intercostal space. The ribs were spread enough to introduce the surgeon’s hand and allowing the usage of different instruments. A suction catheter was introduced into the pleural cavity, into the site of collection, with suction of the fluid as much as possible. Suction and irrigation technique was used. The evacuated pleural fluid was sent for bacteriological evaluation as well as culture and sensitivity tests. Exploring the pleural cavity under direct vision for the presence of other loculations and presence of adhesions was done. Dealing with other cavities by the suction and irrigation technique was done, then, the entrapped lung was freed from adhesions to the chest wall. Decortication of the lung completely, if needed, was done. After complete evacuation of the pleural fluid from the pleural cavity as well as decortication of the lung, adequate lung expansion should be obtained. Two wide bore thoracostomy tubes were introduced into pleural cavity, one was directed to the previous loculated cavity and the other directed towards the apex. Closure of the incision in layers was done.
Postoperative Management:
All patients were transferred to a high care unit, where, both intercostal drain systems were connected to low-pressure suction system. Analgesics in the form of pethidine were given in a dose of 50 mg every 4-6 hours according to the need of the patients. A chest roentgenogram was done just after surgery and then on daily basis. The perioperatively IV broad spectrum antibiotics were continued till the results of the culture sensitivity tests and then for 5 days according to the culture and sensitivity results. Chest tubes were removed once pleural fluid drainage was less than 100 ml and/or stoppage of air leak for 24 hours, we removed the apical one at 1st and the other tube was removed according to the volume of pleural drainage.
Postoperative Assesment and Statistical analysis:
The duration of the procedure in minutes, the total volume of the pleural drainage in the 1st 24 hours, the total volume of analgesics in the 1st 24 hours, the period of preoperative ICT in days, the period of postoperative ICT in days, the period of postoperative air leak, the postoperative hospital stay period, as well as the postoperative return to more or less normal activity period. Complications and recurrence were evaluated. All the results were collected and statistically analyzed using T-test. Statistical analysis was conducted using SPSS (version 7) for windows statistical package. P-value ≤ 0.05 was considered statistically significant.
Results:
This study included 54 patients with chest trauma. They were managed initially with tube thoracostomies to drain hemothorax, but, after 3-5 days, they were claimed to have clotted hemothorax or retained pleural fluid. Twenty-three patients (group I) of them underwent VATS procedure to manage the condition; they were called the VATS group. The other 31 patients (group II) were managed by conventional posterolateral thoracotomy, and they were called thoracotomy group. Table I, II and III as well as fig (1) and (2) summarize all the results and data of the patients:
Twenty patients (87%) of the VATS group (23 patients) were males, while 25 patients (80%) of the thoracotomy group (31 patients) were males. Nineteen patients (83%) of the VATS group patients had history of blunt chest trauma, whereas, 26 patients (84%) of the thoracotomy group had history of blunt chest trauma.
There was no statistical significant difference (P-value > 0.05) between the mean ages of both groups, as the mean age of the VATS group patients was 33 ± 8 years, while it was 32.7 ± 7 years for the thoracotomy group patients. The mean preoperative ICT period was 6 ± 1.5 days for the VATS group patients, and it was 7 ± 2 days for the thoracotomy group patients. It was statistically non-significant.
Table I:Preoperative data:
ITEM / VATS(Group I) / Thoracotomy
(group II) / P-value
Number of Patients / 23 / 31
Mean Age / 33 ± 8 years / 32.7 ±7 years / 0.9
Males / 87% (20/23) / 80% (20/31)
Blunt Chest Trauma / 83% (19/23) / 84% (26/31)
Penetrating Chest Trauma / 17% (4/23) / 16% (5/31)
Preoperative ICT Period / 6 ± 1.5 days / 7 ± 2 days / 0.06
Preoperative empyema (Discovered Intraoperatively) / 13% (3/23) / 23% (7/31)
Intraoperatively, as regard pleural adhesions, it was mild in 18 patients (78%) of the VATS group patients, and in 21 patients (68%) of the thoracotomy group patients, while, it was moderate in 5 patients (22%) of the VATS group patients, and in 6 patients (20%) of the thoracotomy group patients. There were no patients in the VATS group patients having dense or severe pleural adhesions, but, 4 patients (12%) of the thoracotomy group patients were found to have severe or dense pleural adhesions.
Fig (1):Etiology in Both Groups
Preoperatively, there was no patient in the both groups of patients proved to have empyema or infected retained pleural fluid, but, bacteriological examination of the drained pleural fluid intraoperatively revealed empyema in 3 patients (13%) of the VATS group patients, all those 3 patients had moderate pleural adhesions, and empyema was diagnosed in 7 patients (23%) of the thoracotomy group patients, those 7 patients included the 4 patients who were having severe or dense pleural adhesions and 3 patients of the 6 who had moderate pleural adhesions.
There was statistical significant difference (P-value ≤ 0.05) between the VATS group patients and the thoracotomy group patients in the mean operative time (70 ± 4 minutes VS 77 ± 6 minutes respectively), and, mean volume of pethidine in the first 24 hours postoperatively (201 ± 17 mg VS 239 ± 18 mg respectively).
There was also statistical significant difference between the VATS group patients and the thoracotomy group patients in the mean ICT drainage in the first 24 hours postoperatively (219 ± 22 ml VS 230 ± 18 ml respectively),and, mean ICT period postoperatively (4 ± 1 days VS 6.5 ± 1 days respectively).
There was also statistical significant difference between the 2 groups of patients in the mean hospital stay postoperatively (6 ± 3 days VS 10 ± 2.5 days respectively),and, the mean period to return to more or less normal activity (15 ± 1.8 days VS 23 ± 3.5 days respectively).
Table II:Intraoperative and Postoperative data:
ITEM / VATS(Group I) / Thoracotomy
(group II) / P-value
Operative Time (minutes) / 70 ± 4 / 77 ± 6 / 0.00001
Pethidine dose (mg) / 201 ± 17 / 239 ± 18 / 0.00002
ICT drainage (1st 24 hours) / 219 ± 22 / 230 ± 18 / 0.04
ICT period (days) / 4 ± 1 / 6.5 ± 1 / 0.00009
PostoperativeHospital stay (days) / 6 ± 3 / 10 ± 2.5 / 0.00002
Return to normal activity / 15± 1.8 days / 23 ± 3.5 days / 0.000009
As regard complications, the postoperative empyema was diagnosed in one (4%) of the VATS group patients, and, it was found in 3 patients (10%) of the thoracotomy group patients. Reoperation in the form of thoracotomy performed in the only patient who had postoperative empyema in the VATS group, and, it was performed in 2 patients (6%) of the 3 patients who had postoperative empyema in the thoracotomy group, while the last patient was managed conservatively by thoracostomy tube and specific antibiotics.
Fig (2): Intraoperative Findings
The postoperative air leak occurred in 3 patients (13%) of the VATS group patients, and, it was found in 6 patients (20%) of the thoracotomy group patients. Wound infection did not occur in the VATS group patients, and, it was found in 3 patients (10%) of the thoracotomy group patients.
Table III:Other Operative and Postoperative data:
ITEM / VATS(Group I) / Thoracotomy
(group II)
Mild Adhesions / 78% (18/23) / 68%(21/31)
Moderate Adhesions / 22% (5/23) / 20% (6/31)
Severe Adhesions / 0% (0/23) / 12% (4/31)
Postoperative empyema / 4% (1/23) / 10% (3/31)
Postoperative air leakage / 13% (3/23) / 20% (6/31)
Wound Infection / 0% (0/23) / 10% (3/31)
Reoperation due to Empyema / 4% (1/23) / 6% (2/31)
Discussion:
Inadequately drained posttraumatic hemothorax with tube thoracostomy can lead to the complications of fibrothorax/entrapped lung or empyema. (Navsaria et al, 2004), (Lowdermilk and Naunheim, 2000), and, (Heniford et al, 1997).Conventionally,these conditions were managed surgically with open thoracotomy. Video-assisted thoracoscopic surgery (VATS) had emerged as alternative surgical technique in the evaluation and treatment of posttraumatic pleural complications(Navsaria et al, 2004), (Ahmed and Jones, 2004), and, (Smith et al, 1993).
Our study carried out on 54 patients with chest trauma who were proved to have clotted hemaothorax or retained pleural fluid after initial management with thoracostomy tubes. VATS were performed in 23 patients and conventional thoracotomy was done in 31 patients to evacuate the clotted hemothorax or retained pleural fluid as well as freeing the entrapped lung.