Professional Documents
Culture Documents
http://jms.ndmctsgh.edu.tw/2302113.pdf
Copyright 2003 JMS
Background: Traumatic hemothorax without early adequate evacuation of intrathoracic blood often results in
prolonged hospitalization and severe complications such as empyema and fibrothorax. The efficacy of video-assisted
thoracoscopic surgery (VATS) applied on this disease entity was studied. Methods: Chest trauma patients who
developed retained clotted hemothoraces after initial management with chest intubation were prospectively randomized
to treatment with either traditional posterolateral thoracotomy (group 1, n=9) or video-assisted thoracoscopic surgery
(group 2, n=9). In group 1 patients, the goal of operative procedure was to evacuate blood clots, with the thoracotomy
wound being less extensive as possible. Duration of chest tube drainage, total amount of tube drainage, hospital stay
and estimated costs of both groups were studied. Results: Patients in group 2 had shorter duration of postoperative tube
drainage (3.440.68 versus 5.671.53 days; p<0.001), shorter hospital days after the procedure (4.561.06 versus
9.112.64 days; p<0.001), and shorter total hospital stay (8.561.83 versus 15.223.58 days; p<0.001) compared
to group 1 patients. Hospital costs were also less in group 2 (NT$ 51,55616,561 versus 78,65614,105; p<0.001).
There were no mortalities in either group of patients. No conversion to thoracotomy procedure was needed in group 2
patients. Conclusion: VATS performed early on patients who failed the initial chest intubation to treat traumatic
retained clotted hemothoraces significantly decreases the expected time of tube drainage, the length of hospital stay,
and total hospital cost. Thoracotomy itself, relatively time wasting and labor consuming, could be reserved as a second
choice in case there are contraindications to VATS procedure.
Key words: chest trauma, clotted hemothorax, video-assisted thoracic surgery (VATS)
113
VATS for clotted hemothoraces
114
Jeng-Yuan Wu, et al.
115
VATS for clotted hemothoraces
thoracoscope to assess patients after penetrating thoracic treatment for trauma patients with residual intrathoracic
trauma, significantly reducing the risk and need for per- blood collections. In our group 2 patients, VATS was
forming thoracotomy. However, not until the introduction successfully performed on all 9 patients with no convert to
of modern laparoscopy into the trauma setting14-16 did thoracotomy or any other complications. We agreed that
thoracic surgeons begin to reassess the thoracoscopy for failure to achieve acceptable result using thoracoscopy
traumatic applications17. Recent reports have supported correlated with the time interval from injury to operation
the feasibility of VATS for diagnostic procedures. Ochsner and the type of collection such as infected hemothorax or
and associates18 used thoracoscopy to evaluate and verify empyema.
14 patients of initially obscured diaphragmatic injuries. In our experiences, we suggest that early repeat chest
They found that VATS was able to evacuate retained roentgenogram within 72 hours of the initial management
hemothoraces and provide excellent visualization of in- after chest tube insertion will help sorting out who need
trathoracic structures, as well as detecting any associated further surgical interventions. Case selections based on
injuries in an earlier stage and reducing subsequent hemodynamical stability and positive abnormal findings
complications. Later in a similar study, Uribe and col- with retained blood clots in our 18 patients would get the
leagues19 prospectively evaluated 28 patients with tho- best result. In hemodynamically unstable patients present-
racoabdominal penetrating trauma by VATS. Although ing with ongoing hemorrhage after tube thoracostomy, we
this study focused on the utility of VATS for identification strongly recommend immediate open thoracotomy to stop
of diaphragmatic injury, they also noted VATS was useful bleeding.
for evacuation of blood clots from the pleural space. Our We believe that in cases with retained hemothoraces
study showed comparable results in a prospective clinical after chest trauma, the goals of acute management include
trial specifically involving both the thoracotomy and VATS early rapid removal of residual blood clot without awaiting
procedures and illustrated that the latter could practically hematoma formation, simultaneous identification of the
be applied to thoracic trauma patients for both diagnostic sources of bleeding, and treatment of other associated
and therapeutic purposes. intrathoracic injuries. The present study demonstrated that
Early experiences with VATS in the management of the VATS procedure can accomplish these goals in acute
traumatic hemothoraces have been reported in many other trauma setting and significantly improve outcomes of the
studies. Smith and associates20 assessed 24 consecutive patients in terms of reduced duration of tube drainage,
patients with chest trauma by way of thoracoscopy for reduced time of hospital stay after the procedure and
clotted hemothorax. In 8 of 9 patients successful evacua- overall hospitalization and less cost of hospitalization
tion of blood was performed. Five patients were treated for comparing with open thoracotomy procedure. Although
ongoing hemorrhage, with 3 of 5 safely managed by VATS took less operating time than that of thoracotomy in
thoracoscope using diathermy without additional pro- our patients, it showed no statistical significance and might
cedures. Landreneau and colleagues21 used VATS in 23 result from learning curve on this specific disease entity.
patients with retained hemothoraces from various causes Complications after tube thoracostomy, although a rela-
and recommended VATS early in the management of tively simple procedure, may occur in as many as 21% of
patients with retained hemothoraces to avoid the problems patients23. Residual hemothorax or pneumothorax, im-
of secondary infection within the intrathoracic clot or late proper tube positioning, empyema due to secondary
formation of fibrothorax. A recent experience with VATS infection, and direct lung injuries by tube itself have been
for management of retained hemothorax was reported by reported. Thoracoscopy is considered as a safer and more
Heniford and associates22. In their series of 25 patients, 19 effective procedure with complication rates in large series
patients (76%) were successfully treated with VATS. Four less than 10%24. Morbidities such as segmental lung atelecta-
patients (16%) were converted to open thoracotomy, and 2 sis and residual space problems were present only in the
(8%) required additional procedures to drain fluid col- thoracotomy group in our study, with subsequent recovery
lections. Thoracoscopic intervention within 5 days of chest all managed by conservative measures. The possible causes
injury was considered to have higher success rate when of recurrent pneumothoraces or hemothoraces may be due
compared to delayed treatment after average 2 weeks to sequelae of missed small lung parenchymal injuries or
following chest trauma, the latter usually incurring formi- inadequate expansion of the lung. Postoperative atelecta-
dable complications or prolonged hospitalization. Empy- sis is often related to thoracotomy pain that seldom occurs
ema did not develop in cases operated within 7 days of in patients receiving VATS procedure.
injury. These authors recommended VATS as the initial Our data suggest that early using thoracoscopic surgery
116
Jeng-Yuan Wu, et al.
117
VATS for clotted hemothoraces
racoscopy for the diagnosis of penetrating thoracoab- coscopy in the management of retained thoracic col-
dominal trauma. J Trauma 1994;37:650-654. lections after trauma. Ann Thorac Surg 1997;63:940-
20. Smith RS, Fry WR, Tsoi EK. Preliminary report on 943.
videothoracoscopy in the evaluation and treatment of 23. Etoch SW, Bar-Natan MF, Miller FB, Richardson JD.
thoracic injury. Am J Surg 1993;166:690-695. Tube thoracostomy: factors related to complications.
21. Landreneau RJ, Keenan RJ, Hazelrigg SR, Mack MJ, Arch Surg 1995;130:521-526.
Naunheim KS. Thoracoscopy for empyema and he- 24. Krasna MJ, Deshmukh S, McLaughlin JS. Complica-
mothorax. Chest 1995;109:18-24. tions of thoracoscopy. Ann Thorac Surg 1996;61:
22. Heniford BT, Carrillo EH, Spain DA, Sosa JL, Fulton 1066-1069.
RL, Richardson JD. The role of video-assisted thora-
118