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Ann Thorac Surg 1997;63:940-943
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

The Role of Thoracoscopy in the Management of Retained Thoracic Collections After Trauma

Department of Surgery, School of Medicine, University of Louisville, Louisville, Kentucky; and Laparoscopic Institute of South Florida and Veterans Administration Medical Center, Miami, Florida

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Retained hemothorax and infected thoracic collections after trauma can be seen in up to 20% of patients initially treated with tube thoracostomy and have traditionally been treated nonoperatively, often with prolonged hospital stays.

Methods. Twenty-five patients with retained thoracic collections were reviewed. They underwent 26 thoracoscopies to evacuate undrained blood with or without infection.

Results. In 19 patients (76%), the collections were evacuated thoracoscopically. In 4 patients the procedure was converted to an open thoracotomy, and 2 patients required additional procedures to drain these collections. Failure of thoracoscopy correlated with the time between injury and operation and the type of collection, but not with the mechanism of injury. When thoracoscopy was performed in less than 7 days after admission, no cases of empyema were noted at operation.

Conclusions. Videothoracoscopy is an accurate, safe, and reliable operative therapy to evacuate retained thoracic collections. In 90% of the patients in whom the procedure was completed, good results were obtained, reducing hospital stay and possible complications. Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 943.

Improvement in video electronics and endoscopic surgical devices has fostered a renewal of interest in thoracoscopy. Technical advances have allowed surgeons to apply thoracic endoscopic techniques as part of the primary management of some conditions classically managed by open thoracotomy. Some have moved to more complex video-assisted thoracic surgery (VATS) as the treatment of choice for conditions such as retained thoracic collections [1, 2], which often had been previously managed conservatively and were associated with prolonged hospital stays.

Posttraumatic thoracic fluid collections are frequently encountered in trauma centers today. Standard radiologic studies are known to underestimate the size of or be insensitive to the existence of these collections. The widespread use of computed tomographic (CT) scans, whether looking at the chest itself or the abdomen with an "accidental view" of the thoracic cavity, has alerted us to the presence of these unsuspected abnormalities. The incidence of empyema in thoracic trauma is approximately 10% [3–5], and a residual hemothorax is thought to be a major contributing factor [6, 7]. Given this, our own management of posttraumatic retained thoracic collections has evolved from an expectant, nonoperative approach to one of more aggressive therapy.

The purpose of our review was to confirm the advantages of VATS in managing patients with retained thoracic collections after traumatic injuries and to further delineate the indications, utility, and benefits of this modality in thoracic trauma.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Twenty-five patients with retained thoracic collections after traumatic injuries to the chest were managed with VATS from July 1993 through March 1996. Initial experience with 7 patients was begun at the Department of Surgery of the University of Miami, whereas the last 18 patients of this series were treated at the Department of Surgery of the University of Louisville under the supervision of one of us (E.H.C.). A retained thoracic collection was defined as any persistent intrathoracic material, infected or not, that was not able to be drained with a chest tube in 72 hours. Patients in two groups were chosen for thoracoscopic evaluation and management: (1) those with a clotted hemothorax unresponsive to tube thoracostomy and (2) those with a proven or suspected infected thoracic collection unresponsive to tube thoracostomy and systemic antibiotic therapy. A clotted hemothorax was defined as a residual clot estimated to be larger than 500 mL or that occupied at least one third of the involved hemithorax. An infected thoracic collection was defined as a bacteriologically proven infection of any collection in the pleural space, documented before or after VATS.

All procedures were performed in the operating room where patients received general anesthesia and endotracheal intubation. It is our current practice to have a double-lumen endotracheal tube placed to facilitate collapse of the ipsilateral lung and to optimize visualization of the thoracic cavity. Intraarterial pressure, pulse oximetry, end-tidal CO₂, and cardiac activity were routinely monitored during all operations.

Once airway control had been obtained, the patients were placed in the corresponding full lateral decubitus or modified lateral position on a "bean bag," with their ipsilateral arm abducted 90 degrees at the shoulder, flexed at the elbow, and supported on a stand. Care was taken to place the arm to allow motion that facilitated exposure and avoided injury during retraction. Adhesive tape secured the patients' hips to the operating table. Proper positioning of the patients was extremely important to facilitate the placement of the thoracoscope and additional instruments, facilitate visualization of the entire thoracic cavity, and ensure that an open thoracotomy could be performed if the endoscopic procedure was aborted.

Standard thoracoscopy equipment was used, including a scope with a 0-degree angle with 16x magnification and a xenon light source, and one high-resolution video monitor. In the initial stages of this experience, we used two monitors and had a 30-degree angle scope available, but we believe that neither adds significant advantage. We do not use thoracic insufflation for lung deflation because a well-placed double-lumen endotracheal tube will facilitate lung collapse. We use 10-, 12-, and 15-mm Thoracoports (United States Surgical Corporation, Norwalk, CT) to place the camera and the working instruments.

The thoracoscope is introduced through a 2-cm intercostal incision in the fifth or sixth intercostal space in the midaxillary line, or by using an existing thoracostomy tube incision. One or two additional incisions are made; the locations of the extra incisions are determined after the initial inspection is completed. When possible, additional incisions are made at the same interspace level to allow incorporation into a thoracotomy incision. In our current practice, ports are rarely used and most work is performed directly through the chest wall. Standard nondisposable instruments are used [8].

Deflation of the lung by single-lung ventilation should be obtained before instruments are placed. If complete lung collapse cannot be achieved because of early adhesions, blunt and digital dissection are used to facilitate decompression. Blood and clots are cleared with the standard suction instrument or a suction/irrigator system. A sample of fluid is collected for microbiological assessment.

In patients with more organized thoracic collections, gentle dissection and peeling with sponge sticks and ring forceps usually allows the rind to be removed from the visceral and parietal pleuras, completely releasing the trapped lung. Two large-bore chest tubes are placed, one each at the site of our working and thoracoscope incisions. The thoracostomy tubes remain on continuous suction until the amount of drainage from the thoracic cavity is less than 100 mL/day, which in most cases occurs by postoperative day 3.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Twenty-six VATS procedures were performed in 25 patients. One patient who sustained a transmediastinal gunshot wound required bilateral drainage of retained hemothoraces. There were 23 men and 2 women, aged 18 to 54 years (average, 26 years). Fifteen sustained penetrating trauma (gunshot wounds in 11 and stab wounds in 4) and 10 had blunt injury. The mean length of hospital stay was 22 days (range, 4 to 58 days); however, the median time between admission and VATS was 7 days, and the median interval between VATS and discharge from the hospital or the resolution of the thoracic collection was 7 days (range, 3 to 10 days). In patients in whom thoracoscopic drainage was unsuccessful, the mean time between admission and operation was 14.5 days. In patients in whom VATS proved successful, the mean interval between admission and operation was 4.5 days. The operative time in patients with noninfected thoracic collections was less than 1 hour. Operative findings were retained hemothorax in 20 patients and empyema in 6. No empyema was observed in patients treated successfully within 7 days of admission; 2 patients treated successfully more than 7 days after admission had empyema. The procedure was successful in 19 patients (76%), with complete evacuation, early chest tube removal, and absence of reaccumulation of fluid. Two patients had suboptimal results because further procedures were needed for removal of persistent or reaccumulated thoracic collections. In these 2 patients the indications for VATS were an empyema and retained hemothorax; the operations were performed at 8 and 10 days after admission, respectively. One patient required multiple tube thoracostomies postoperatively, whereas the other had CT-guided drainage of several, small localized collections.

Four patients required conversion to an open thoracotomy because of inability to adequately evacuate the collection or expand the lung. These patients were operated on 9 to 22 days after the injury (average, 17 days). Three of these patients had empyema as their indication for operation; therefore, 4 of the 6 cases with suboptimal or unsatisfactory VATS had empyema as the reason for operation. Mechanism did not correlate with unsuccessful VATS as 2 patients had gunshot wound, 1 had a stab wound, and 1 suffered a blunt injury.

There were no deaths or life-threatening complications in these patients. No significant cardiac or respiratory complications developed during the procedure, although 3 patients had transient arterial oxygen desaturation, which corrected after resumption of bilateral lung ventilation. Pneumonia was observed in 5 patients postoperatively; 3 of these had an open thoracotomy for empyema drainage. Local wound infection occurred in 3 patients: in 2 it complicated an open thoracotomy, and 1 thoracoscopy patient had a persistent air leak that resolved after 10 days of suction drainage. Complete resolution was usually not observed on the chest radiograph before postoperative day 3; however, near-complete resolution was usually seen on chest roentgenograms by the fifth day postoperatively. The median length of hospital stay was 7 days (range, 3 to 10 days) for patients with hemothorax and 22 days (range, 4 to 58 days) for patients with empyema.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Residual thoracic collections after traumatic injuries to the chest are a well-recognized complication occurring in 5 to 30% of patients and are a major risk factor for the development of empyema [3–6]. With the continuous development and use of CT scan of the chest, the diagnosis of retained thoracic collections currently is being done in a more expeditious manner. Plain chest films, especially when done with portable equipment, can be extremely misleading and usually underestimate the true extent of a thoracic collection. Computed tomography of the chest is extremely useful in identification of parenchymal conditions, retained hemothorax, and infected collections [9–14]. As we have demonstrated, thoracoscopy can be an effective method to treat these retained thoracic collections, especially when found early.

Approximately 20% of patients with a hemothorax initially managed with tube thoracostomy will continue to have a residual clot; about 40% of these will require thoracotomy to drain these collections [15]. If untreated, the natural history of blood in the chest is variable; hence the uncertainty in prescribed treatment. In some cases the collections may absorb, develop into a fibrothorax, or become an empyema [1, 6, 10]. Early evacuation of a retained hemothorax has been shown to effectively decrease the incidence of the complications of empyema and fibrothorax and facilitate the overall management of these patients [1, 6, 7, 9]. As our results indicate, early diagnosis and treatment are extremely important. If after 2 days of conventional management there is radiographic or clinical evidence of a continuing significant opacity in the thorax, we obtain a chest CT scan to differentiate between a primary parenchymal process and a retained hemothorax. If a hemothorax is present, the CT allows a rough quantification of the blood present. If the CT scan shows a hemothorax larger than 500 mL or one third or more of the hemithorax to be involved, we proceed with elective VATS; if it is less, the patients are closely observed. Thrombolytic agents were not used in these patients.

Infected thoracic collections are seen in 2% to 8% of patients who have sustained thoracic injuries [4, 5, 9, 10]. Retained hemothorax is the most common precipitating factor and usually is associated with multiple attempts at drainage by tube thoracostomy. Our 6 patients with empyema, all of whom underwent operation on or later than the eighth postoperative day, lend credence to the recommendation for more aggressive management of retained thoracic collections. In patients in whom VATS was performed less than 7 days after the injury, pleural infections did not occur. Despite our relative lack of success with the thoracoscopic management of empyema (one half of the patients required open thoracotomy to complete the initial operation), in patients in whom we suspect a post-traumatic pleural infection, it remains our practice to proceed directly to VATS, which is liberally extended to a full thoracotomy if needed.

Despite initial concerns regarding its efficacy and safety, VATS has been tested and shown to be a safe, reliable, and useful technique [1, 2, 16–18], but its use should be considered carefully in patients in whom it may not be feasible because of (1) compromised pleural cavity due to previous empyema, granulomatous infections, or thoracotomy and (2) inability to tolerate single-lung ventilation secondary to contralateral pulmonary resection, acute or chronic severe respiratory insufficiency, high levels of required oxygen on mechanical ventilation, or hemodynamic instability. Bleeding diathesis is regarded as a relative contraindication [8].

In summary, our experience in using VATS to manage retained thoracic collections after trauma suggests that it is a safe and reliable form of operative therapy. In the 90% of our patients in whom the procedure was completed, we had good results in spite of our simple technical approach, which is only slightly more invasive than a tube thoracostomy. We believe that early VATS is currently the treatment of choice for these patients.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Presented at the Forty-third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7–9, 1996.

Address reprint requests to Dr Carrillo, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY 40292 (e-mail: ehcarr01{at}ulkyvm.louisville.edu).

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eddy H. Carrillo Robert L. Fulton Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Heniford, B. T. Articles by Richardson, J. D. Search for Related Content PubMed PubMed Citation Articles by Heniford, B. T. Articles by Richardson, J. D. Related Collections Related Article