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Ann Thorac Surg 2001;72:342-347
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

^a Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA

Address reprint requests to Dr DiMaio, Department of Cardiothoracic Surgery, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
e-mail: michael.dimaio{at}utsouthwestern.edu

Presented at the Forty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 9–11, 2000.

	Abstract

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Background. Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma.

Methods. A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI.

Results. One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound.

Conclusions. In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.

	Introduction

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Injuries to the diaphragm occur in 3% to 5% of patients who sustain penetrating chest trauma and are associated with an increased risk of major morbidity and mortality [1–7]. Diaphragmatic injuries (DIs), however, can be difficult to diagnose and, when missed, can result in a chronic diaphragmatic hernia, with the potential for incarceration, strangulation, and death. Video-assisted thoracoscopic surgery (VATS) has been shown to improve the sensitivity, specificity, and accuracy of identifying DIs after trauma [8]. The purpose of this study was to establish specific indications for the use of VATS to diagnose DI by identifying independent risk factors for injuries to the diaphragm after penetrating chest trauma.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Discussion References

 
A retrospective review of all patients undergoing VATS after penetrating chest trauma seen at Parkland Memorial Hospital between January 1992 and December 1999 was performed. During this 8-year period, patients who were thought to be at risk for DI after penetrating chest trauma without a separate indication for celiotomy or thoracotomy underwent VATS on the basis of criteria in a previous publication [9]. Only patients in hemodynamically stable condition with an isolated, unilateral penetrating chest injury were eligible for inclusion in the study. The medical records of these patients were reviewed for demographics, injury mechanism, entry wound location, presenting symptoms, physical findings, noninvasive and invasive diagnostic testing, associated injuries, VATS findings, morbidity, and mortality. When identified, DIs were graded using diaphragm organ injury scale of the American Association for the Surgery of Trauma [10]. As our interest was in predicting injuries to the diaphragm requiring surgical repair, grade I injuries were not considered DIs for the purposes of this investigation.

VATS technique
Unilateral VATS was performed after the induction of general anesthesia using a single- or double-lumen endotracheal tube with the patient in the lateral decubitus position. A 10-mm thoracoscopy post was placed through an incision in the seventh intercostal space in the midaxillary line to allow the introduction of a 30-degree rigid videothoracoscope (Karl Storz Endoscopy-America, Inc, Culver City, CA). The entire hemidiaphragm along with the parietal pleura, lung, chest wall, and pericardium was inspected for signs of injury. Occasionally, a second 5-mm incision was made to allow for the insertion of an instrument or suction cannula to facilitate visualization or allow for the evacuation of a hemothorax. A single 32F chest tube was placed to the apex of the hemithorax through the camera port when no injuries were identified. If a lung injury or a DI was recognized, apical as well as inferior right-angled tube thoracostomy was used to drain the chest. Isolated apical chest tubes were placed on a water seal 12 hours after operation and removed the morning of the first postoperative day.

Statistical analysis
Continuous data are expressed as the mean ± the standard deviation of the mean except where otherwise indicated. Differences between categorical variables were evaluated by Fisher’s exact test. Differences between continuous variables were measured by the two-tailed Student t test. Independent risk factors for injuries to the diaphragm were identified from the previously listed variables using a forward stepwise logistic regression model (Prism; Graph Pad Software Inc, San Diego, CA). A significance level of 0.05 was required for a variable to be retained as a risk factor for DI.

	Results

Top Abstract Introduction Material and methods Results Comment Discussion References

 
During the study period, 171 patients who met the inclusion criteria were referred for VATS to exclude a DI after penetrating chest trauma. Sixty patients (35%) were found to have a DI by VATS (DI group). During the same period, 42 DIs were recognized in the study institution in patients who did not require VATS. The characteristics of the DI group were compared with those of the 111 patients (65%) who did not have a DI (no-DI group) (Table 1). Mean age and sex were comparable between the two groups. A high-velocity mechanism of injury was more common in the DI group than in the no-DI group (p = 0.0007). Entry wound location for the two groups are shown in Figure 1. Diaphragmatic injuries were significantly more common when the entrance wound was inferior to the nipple line (p = 0.0004) and on the right side of the chest or back (p = 0.006).

View larger version (19K): [in this window] [in a new window]   Fig 1. Entrance wound locations. (A) Front; (B) back. Numerator depicts the number of diaphragm injuries. Denominator depicts the total number of entrance wounds in that area.

Forty-seven patients (78%) in the DI group had an associated intraabdominal injury identified by diagnostic peritoneal lavage (2 patients), computed tomographic imaging (18 patients), or during celiotomy (27 patients) to repair the DI. These injuries involved the liver (24 patients), spleen (11), stomach (5), kidney (3), colon (2), and small bowel (2 patients). Minimal or no intervention was required at the time of celiotomy for 14 liver and three splenic injuries, which would have been treated nonoperatively if not for the DI. Of the 111 patients found not to have a DI by VATS, 41 (37%) had an intraabdominal injury recognized by diagnostic peritoneal lavage (3 patients), computed tomographic scan (36), or ultrasound (2). Twenty-three of these patients underwent celiotomy for the treatment of liver (9 patients), spleen (8), stomach (3), or renal injuries (3 patients). The other 18 patients had minor injuries to the liver (10) or spleen (7) or a periphrenic hematoma (1) and were treated in a nonoperative fashion.

Intrathoracic injuries were common in both groups of patients. In the DI group, the following associated intrathoracic injuries were found: lung laceration (11 patients), penetration of the pericardium (5), intercostal vessel injury (6), phrenic nerve hematoma or transection (3), and periaortic (3) or periesophageal hematoma (2 patients). These resulted in four VATS wedge resections to control parenchymal lung bleeding, five VATS pericardial windows, and nine VATS hemothorax evacuations. Conversion to a thoracotomy was required to achieve hemostasis for lung (3 patients) or intercostal vessel injuries (3) or to inspect periesophageal (2 patients) or periaortic hematomas (2). In the no-DI group, the following associated injuries were found: lung laceration (18 patients), pericardial penetration (7), intercostal vessel injury (10), phrenic nerve hematoma or transection (5), or periesophageal hematoma (4 patients). Video-assisted thoracoscopic procedures were used to perform seven stapled wedge excisions for bleeding of the lung, seven pericardial windows, and eight hemothorax evacuations. Conversion to a thoracotomy was required to achieve hemostatsis in lung (3 patients) or intercostal vessel injury (3) or to inspect a periesophageal hematoma (4).

Of the 60 patients found to have a DI, 42 (70%) had injuries to the right hemidiaphragm (See Fig 1). The majority of DIs in this series were of low to moderate grade in severity: grade I, 0; grade II, 31; grade III, 19; grade IV, 8; and grade V, 2. Fifty-six (93%) of the DIs were repaired through a celiotomy, three (5%) through a thoracotomy, and one (2%) with laparoscopy. In this series, no DI was repaired using VATS, and prosthetic material was required in only one DI repair.

Major morbidity occurred in 31 patients (52%) in the DI group and 39 (34%) in the no-DI group (p = 0.03) (Table 2). Complications related to VATS included five wound infections and one instance of bleeding at a trocar site. That patient had to be returned to the operating room. Four patients (7%) in the DI group died in the hospital. The causes of death were adult respiratory distress syndrome and multiple-system organ failure (2 patients), myocardial infarction (1), and pulmonary embolism (1) (see Table 2). Four patients (4%) in the no-DI group died during hospitalization as a result of adult respiratory distress syndrome, multiple-system organ failure, myocardial infarction, pneumonia, and pulmonary embolism (1 patient each). In the DI group, the mean length of hospital stay was 9 ± 4 days (range, 5 to 49 days), and in the no-DI group, the mean length of hospital stay was 4 ± 3 days (range, 1 to 38 days).

	Comment

Top Abstract Introduction Material and methods Results Comment Discussion References

Identifying a DI after penetrating chest trauma remains a challenge for the surgeon, as evidenced by the large number of investigative techniques used for this purpose. Noninvasive methods, such as chest radiography and computed tomography, have mean accuracy rates of less than 50% [12–14]. Contrast radiography and radioisotopic scintigraphy can be of value in recognizing chronic DIs, but their usefulness in the acute setting has become limited [5, 15]. Invasive diagnostic methods have included iatrogenic pneumoperitoneum, diagnostic peritoneal lavage, and pleuroperitoneal lavage. However, all of these techniques are associated with excessive false-negative rates when used to identify DIs. Diagnostic peritoneal lavage, currently the most commonly used method to evaluate the abdomen after trauma, fails to recognize major DIs even when the effluent has fewer than 1,000 red blood cells/mm³ [16–18]. This led Madden and colleagues [19] to recommend that all patients at risk for a DI after penetrating chest trauma undergo celiotomy. Specifically, they advised celiotomy for patients with entrance wounds of the epigastrium or inferior to the fourth, sixth, or eight intercostal space anteriorly, laterally, or posteriorly, respectively.

Celiotomy remained the procedure of choice for recognizing DIs after penetrating chest trauma until minimally invasive surgical techniques began to be applied to trauma patients. Ivatury and coworkers [20] published the first series in which patients sustaining penetrating chest trauma underwent laparoscopy in an attempt to identify DIs. In their initial series of 40 patients, eight DIs in 7 patients were identified that were not suspected after either diagnostic peritoneal lavage or abdominal computed tomography. Later confirmed in larger series reported by Ivatury [21], Salvino [22], and their associates, these findings initiated interest in using minimally invasive maneuvers to identify DIs.

Video-assisted thoracoscopic surgery was first reported as a method of recognizing DIs by Ochsner and coauthors [8]. Subsequently, seven reported series with 140 cumulative patients confirmed the safety and accuracy of VATS in identifying DIs [9]. These series also found several advantages of VATS over laparoscopy or celiotomy including visualization of the entire hemidiaphragm, especially on the right, and the ability to identify and treat other intrathoracic injuries. Furthermore, unlike laparoscopy, VATS does not have the potential to decrease preload because of carbon dioxide insufflation nor does it predispose patients to the possible complication of intraperitoneal adhesions.

With VATS established as a safe and accurate technique for recognizing DIs, the principal purpose of this investigation was to stratify patients into different categories of risk of DI after penetrating chest trauma. Independent historical or clinical predictors were then used to construct an algorithm that would be sensitive and specific for DIs and reserve VATS for patients at major risk for occult injuries to the diaphragm. As expected, high-velocity injury mechanism and entrance wounds located inferior to the nipple line or scapula were found to be independent predictors of DIs. An association between intraabdominal injuries and DIs was also recognized and is important to include in the design of any diagnostic algorithm. Morbidity and mortality for the study population are comparable to those in previous reviews and, although only approaching significance, reinforce the belief that patients sustaining a DI have increased incidences of major complications and death. [1–7].

Several unexpected results were found in this review. The strong association between DI and a pneumothorax or a hemothorax on initial chest radiograph appears to contradict the finding in some reports [23]. However, the majority of previous series combined blunt and penetrating mechanism of injury, and this could dilute the predictive value of the chest radiograph for identifying DIs resulting from penetrating chest trauma. It is not surprising that a penetrating mechanism of injury would be much more likely to injure the chest wall or lung prior to reaching the diaphragm than would a blunt injury mechanism. Also not predicted were the ponderance of right-sided DIs and the frequency of intraabdominal injuries in patients without a DI. The former appears to contradict findings in earlier reports. However, as previously discussed, blunt mechanisms predominated in those series with the higher incidence of left-sided DIs ascribed to the force-buffering effects of the liver on the hemidiaphragm on the right side and the relative congenital weakness of the hemidiaphragm on the left side. The latter finding was likely the result of undetected thoracoabdominal trauma and the sensitivity of high-resolution computed tomography, which detected even trivial solid-organ injuries.

The independent predictors identified in this investigation allowed the construction of a diagnostic algorithm for patients in hemodynamically stable condition who sustain isolated penetrating chest trauma. This strategy emphasizes the need of an early, objective evaluation of the abdomen and chest with diagnostic peritoneal lavage, or computed tomographic imaging, or both, and an upright chest radiograph, respectively. On the basis of these initial tests, patients with indications for celiotomy or thoracotomy can have the hemidiaphragm evaluated at that time (Fig 2). Patients in whom celiotomy or thoracotomy are not warranted and whose history or physical examination identifies two or more independent predictors of DI ( 2 in the algorithm) should undergo VATS to evaluate the hemidiaphragm (Fig 3). For the rare patient with a contraindication to VATS, the diaphragm could be evaluated by magnetic resonance imaging.

View larger version (29K): [in this window] [in a new window]   Fig 2. Diagnostic algorithm for diaphragm injuries following penetrating chest trauma. (1 = The chest is immediately evaluated with an upright chest x-ray (CXR); 2 = The abdomen is evaluated for injury utilizing diagnostic peritoneal lavage (DPL) or computed tomographic (CT) imaging; 3 = Patients with an indication for celiotomy or thoracotomy have their diaphragm evaluated at the time of surgery. VATS = video assisted thoracoscopic surgery.)

View larger version (17K): [in this window] [in a new window]   Fig 3. Diagnostic algorithm for diaphragm injuries (DI) following penetrating chest trauma. (1 = Patients whose history or physical exam identifies two or more ( 2) predictors of DI should undergo video-assisted thoracoscopy to exclude an occult DI; 2 = Patients with less than two (< 2) independent predictors of DI have a risk of occult diaphragm injury too low to justify the routine use of video-assisted thoracoscopic surgery (VATS). Abd = abdomen; CXR = chest x-ray; MRI = magnetic resonance imaging.)

	Discussion

Top Abstract Introduction Material and methods Results Comment Discussion References

 
DR THOMAS D’AMICO (Durham, NC): That was a very interesting series, and I enjoyed your presentation very much. I have a few technical questions. How many of the patients had a positive diagnostic peritoneal lavage that did not cause a pleural effusion, and yet you still thought there was an injury to justify a thoracoscopic approach? Usually, the diagnostic peritoneal lavage will reveal the presence of an injury, and it does not need to be verified thoracoscopically.

Did you repair all the right-sided diaphragmatic injuries that you saw, or were some at the dome of the liver where you thought they would not be a problem?

Why did you not do any thoracoscopic repairs, especially for the low-velocity injuries? They are relatively simple to do. You began with a dual-lumen endotracheal tube with the patient in the lateral decubitus position. Why would you then switch the patient to the supine position, thereby repairing the injury in a more difficult manner?

DR FREEMAN: Thank you for your comments. The number of patients who had a diagnostic peritoneal lavage in this series was low. The members of the trauma division at our institution are not proponents of this technique.

None of these diaphragmatic injuries were repaired thoracoscopically because we thought the incidence of associated intraabdominal injuries was high enough that we did not want to repair a diaphragmatic injury through the chest only to discover an unrecognized intraabdominal injury.

As for injuries over the dome of the liver, we excluded grade I diaphragmatic injuries from the study because we were interested in looking at injuries that needed to be repaired. Therefore, patients with very small contusions or very small lacerations were not included in the series. All diaphragmatic injuries in this series were repaired operatively.

	References

Top Abstract Introduction Material and methods Results Comment Discussion References

 

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This Article Abstract Full Text (PDF) 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): Richard K. Freeman Michael E. Jessen Dan M. Meyer Michael A. Wait Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Freeman, R. K. Articles by DiMaio, J. M. Search for Related Content PubMed PubMed Citation Articles by Freeman, R. K. Articles by DiMaio, J. M. Related Collections Lung - other