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Ann Thorac Surg 2004;78:282-285
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Thoracoscopic evacuation of retained posttraumatic hemothorax

^a Department of Surgery, Trauma Unit, Groote Schuur Hospital and the Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Accepted for publication November 21, 2003.

^* Address reprint requests to Dr Navsaria, Trauma Unit–C14, Groote Schuur Hospital, Anzio Rd, Observatory 7925, Cape Town, South Africa
e-mail: navsaria{at}uctgsh1.uct.ac.za

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: Residual posttraumatic hemothoraces occur in 1% to 20% of patients managed with tube thoracostomy. Video-assisted thoracoscopic surgery (VATS) has emerged as an alternative to thoracotomy to evacuate these retained collections. This report reviews a recent trauma unit experience with thoracoscopic evacuation of hemothoraces.

METHODS: The records of all trauma patients undergoing surgical intervention for retained hemothoraces over the 30-month period January 2001 to June 2003 were reviewed.

RESULTS: The study included 46 patients. All sustained penetrating injuries, 40 with stab and 6 with gunshot wounds. Twenty-two, 17, and 7 patients each had one, two and three attempts at drainage with tube thoracostomy, respectively. In 37 patients (80%), retained infected/uninfected pleural fluid was successfully evacuated thoracoscopically. VATS failed in 9 (20%) patients and the procedure was converted to open thoracotomy. Dense adhesions were present in all 9 of these patients. The mean time interval between injury and thoracoscopy and thoracotomy, was 13.3 days (range 3–46 days) and 14.5 days (range 11–24 days), respectively. The mean volume of pleural fluid evacuated thoracoscopically was 650 mL. The failure of VATS evacuation correlated with the empyema rate. The median postoperative stay was 5 days for both groups.

CONCLUSIONS: Video-assisted thoracoscopic surgery is an accurate, safe, and reliable operative therapy for retained posttraumatic pleural collections, even in patients presenting later than the conventionally accepted 3- to 5-day window from the time of injury.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Inadequately drained posttraumatic hemothorax with tube thoracostomy can lead to the complications of fibrothorax/entrapped lung or empyema. Conventionally, these conditions are managed surgically with open thoracotomy. Video-assisted thoracoscopic surgery (VATS) has emerged as an alternative surgical technique in the evaluation and treatment of posttraumatic pleural complications. Notably, retained hemothoraces have been successfully evacuated and are currently indicated as one of the most suitable conditions amenable to thoracoscopic surgery. We report on our experience, and describe our thoracoscopic technique used in the evacuation of posttraumatic retained hemothoraces.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Over the 30-month period January 2001 to June 2003 the records of all patients with posttraumatic retained pleural collections that underwent surgical evacuation were reviewed. Patients with clotted hemothoraces, and those with a suspected or proven infected pleural collection, were identified for thoracoscopic evaluation and management. 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 surgery. Patients with persistent opacities (> 33% involvement of a hemithorax) on chest radiograph and those with persistent opacities with signs of intrathoracic sepsis (fever, raised white cell count, purulent drainage) were evaluated with a thoracic spiral computed axial tomography (CAT) scan. Patients with residual opacities with multiple air-fluid levels or localized run-off on lateral decubitus chest radiographs with failure to drain with tube thoracostomy underwent surgery without a thoracic computed tomographic (CT) scan. In the operating room, all patients underwent general anesthesia with double lumen endotracheal intubation. All patients were administered intravenous antibiotic combination of amoxicillin and clavulinic acid perioperatively. This was continued for a maximum of 24 hours. Thereafter, therapy was directed according to microscopy, culture, and sensitivity results. Empyemas were managed with 4 weeks of oral antibiotic administration and sterile cultures (ie, presence of white blood cells [WBC] and no organisms) with 1-week oral amoxicillin and claviulinic acid, and those with no WBC and no culture with 24-hour postoperative intravenous amoxicillin and calvulinic acid only. Patients were placed in the corresponding full lateral decubitus position to facilitate conversion to a posterolateral thoracotomy if required. Standard thoracoscopy equipment was used, including a scope with a zero-degree angle with 16x magnification and a xenon light source, and a single high-resolution video monitor. No positive-pressure insufflation was used. A 2-cm incision was placed directly over the site of the loculated collection as determined from the CT scan or lateral chest radiograph. A suction catheter was inserted into the pleural cavity, into the loculated collection, and as much of the pleural fluid removed. Pleural fluid was sent for microbiologic assessment. A 10-mm trocar with the telescope was introduced into the loculated cavity. Another 2-cm incision was placed 8 to 10 cm away from the initial incision, along the same intercostal space, and the suction catheter was introduced through this incision. Further evacuation of the pleural contents was performed under direct vision with the camera. Ring forceps was used to remove rind from the visceral and parietal pleura. Gentle dissection under direct vision with sponge sticks and ring forceps released the trapped lung. Thus, the procedure was performed from within the loculated collection, gently releasing the adherent lung from the chest wall toward normal lung. Once all the pleural fluid and fibrin was evacuated, adequate lung expansion was observed by ventilating the ipsilateral lung. Two thoracostomy tubes were placed postoperatively into the port sites; one into the previous loculated cavity and another directed toward the apex. All patients were transferred to a high-care unit where both intercostal drains were placed onto low-pressure suction. A chest radiograph was obtained, blood for arterial blood gas taken, and routine monitoring of vital signs performed. All patients received physiotherapy twice daily. Chest tubes were removed once pleural drainage was less than 50 mL or when the air leak had stopped for 12 hours. The statistical package STATA 7.0 (Stata Statistical Software, Release 7.0; Stata Corporation, College Station, TX) was used to conduct statistical analysis. The difference in medians and proportions was tested using the Mann-Whitney and the Z-test, respectively. Statistical significance was defined as p less than 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Of the 1054 patients admitted during the study period requiring or admitted with tube thorocostomy, there were 46 patients (4.4%) with a retained pleural collection. Of note, is that 44 patients (96%) were referred with a suspected retained thoracic collection from neighboring hospitals. Only 2 patients initially managed in the unit developed a residual hemothorax resulting in a 0.2% residual hemothorax rate. There were 40 men and 6 women with a mean age of 29.3 years old (range 18 to 49 years old). All patients sustained a penetrating injury, with stab and gunshot wounds accounting for 40 and 6 of the retained collections, respectively. Before referral, 22, 17, and 7 patients each had one, two, and three attempts at pleural fluid drainage with tube thoracostomy, respectively. The 2 patients managed initially in the unit had a single tube drainage procedure only. Thirty-two patients had a spiral CAT scan of the chest illustrating a loculated, retained pleural collection. The remaining 14 patients had residual opacities on chest radiograph with multiple air-fluid levels or run-off on lateral decubitus chest radiographs with failed attempts to drain with tube thoracostomy. Thoracoscopic evacuation of the pleural fluid was successful in 37 patients (80%) and 9 patiens (20%) required conversion to standard thoracotomy.

Analysis of thirty-seven patients undergoing successful VATS evacuation
Only 6 patients were afebrile at the time of surgery. The remaining 31 had a mean fever of 38.4°C (range 37.8–39.9°C). The mean time from injury to thoracoscopy was 13.3 days (range 3 to 46 days), with a median of 10 days. Inadequate lung deflation under general anesthetic with double lumen endotracheal intubation occurred in 28 patients (76%) in this group. The mean operative time was 62.6 minutes (range 30–85 minutes), and the mean volume of retained fluid evacuated was 678 mL (range 300–1700 mL). The bacteriologic profile of the pleural fluid determined from intraoperative pus swab results were: 19 patients (51.4%) had no white cells, no organsims, and negative culture after 72 hours; 9 patients (24.3%) had positive white cells, no organisms, and negative culture after 72 hours; and 9 patients (24.3%) had an empyema. Empyema pleural fluid culture results revealed 6 patients with Staphylococcal aureus, 1 patient with Streptococcus sanguines, 1 with mixed organisms, and 1 patient with three Gram-negative organisms (Bacillus cereus, Klebsiella pneumoniae, and Acinetobacter species). Full lung expansion was visualized in all patients intraoperatively and confirmed with postoperative chest radiographs. Two patients sustained iatrogenic minor lung lacerations during the VATS procedure. These were left alone and did not adversely influence hospital stay or tube thoracostomy removal. Tube thoracosotmy was removed at a median of 4 days (range 2–9 days). The median postoperative stay was 5 days (range 3–12 days). There were no recurrences of pleural fluid at 2- and 6-week clinical and radiologic follow-up.

Analysis of nine patients requiring conversion to thoracotomy
Severe pleural inflammatory reaction resulting in dense adhesions, thus precluding camera insertion and VATS evacuation, was the main reason to convert to thoracotomy. All except 1 patient was febrile with a mean temperature of 38.5°C (range 37.5–39.3°C). The white cell count was raised in all patients with a mean of 18.3 cells mL³ (range 14 to 30.6 cells mL³). The mean time delay from injury to thoracotomy was 14.5 days (range 11–24 days), with a median of 12 days. The mean volume of fluid recovered at thoracotomy was 738 mL (range 100–3000 mL). The macroscopic appearance of the pleural fluid was purulent in 8 patients and bloody in the other. The bacteriological profile was as follows: 7 empyemas (6 with S. aureus, 1 with Klebsiella pneumoniae), and 2 sterile purulent collections (positve white cells and no culture after 72 hours). Full lung expansion was visualized in all patients intraoperarively and confirmed with postoperative chest radiographs. One patient developed superficial wound sepsis of the thoracotomy wound. This was managed with suture removal and dressings as an outpatient. Tube thoracosotmy was removed at a median of 3 days (1–7 days) in 8 patients. One patient with an empyema had the tube thoracostomy cut short and a drainage bag applied for persistent purulent drainage. This was removed at 2-week follow-up. The residual draining sinus eventually closed approximately 7 weeks after surgery. There was no recurrence of clinical or radiologic evidence of empyema or pleural fluid at 2- and 6-week follow-up. The median postoperative stay was 5 days (range 3–28 days).

Apart from dense adhesions precluding access to the pleural cavity and conversion to thoracotomy (100%), the failure of VATS evacuation correlated with the bacteriologic assessment of the pleural fluid. The empyema rate was lower in the thorocoscopy group compared with the thoracotomy group, 24.3% (95% confidence interval [CI] 50–100) and 78% (95% CI 10–38), respectively. This difference in proportion was statistiscally different (p = 0.0013). The failure of VATS evacuation did not correlate with the median time elapsed from injury to surgery: 12 days for thoracotomy versus 10 days for thoracoscopy (p = 0.139). The median postoperative stay in the two groups was the same, 5 days, and not statistically different (p = 0.132). The median time to tube thoracostomy removal in the thoracotomy and thoracoscopy groups was 3 and 4 days, respectively, and not significantly different (p = 0.137).

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Retained hemothorax reportedly occurs in 1% to 20% of patients with chest trauma [1]. Using a protocol based on vigorous physiotherapy and early withdrawal of tube thoracostomy in 1845 patients, retained hemothorax and empyema rates of 2.7% and 0.5%, respectively, were reported by Knottenbelt and associates [2] from our trauma unit. The complications of entrapped lung and empyema following inadequately drained pleural blood has traditionally been managed by thoracotomy. Coselli and coworkers [3] reported a study that strongly supports early drainage in such cases. They reviewed 4000 patients requiring chest tube for hemothorax. A thoracotomy was necessary for 3.8% of patients for fibrothorax and empyema. The mortality for early evacuation (< 5 days) was 0% compared with mortality rates of 1.6% and 9.4% for patients who progressed to decortication or empyema, respectively.

Video-assisted thoracoscopic surgery (VATS) has been revitalized with the advent of improved imaging technology and the evolution of endoscopic instrumentation. The current role of VATS in trauma includes evaluation and control of continued chest tube bleeding, early evacuation of retained hemothorax, evacuation and decortication of posttraumatic empyemas, evaluation and limited treatment of suspected diaphragm injuries, evaluation and treatment of persistent air leaks, and evaluation of mediastinal injuries [4].

The use of VATS in the early evacuation of posttraumatic retained hemothorax has been well documented. Villavicencio and colleagues [5], in a review analyzing the role of thoracoscopy in retained hemothorax, identified eight studies with a total 99 patients [6–13]. Evacuation by VATS was successful in 89 of 99 patients (90%). Mean postinjury day to operation varied among the studies, and ranged from 4.3 to 10.8 days. Technical failures during VATS evacuation occurred as a result of poor visualization from incomplete lung deflation, dense adhesions, or clotted blood. Despite the 10% failure rate, all the studies recommended early VATS evacuation to avoid complications of fibrothorax and empyema. Several of the authors described a window period for the VATS evacuation of less than 3 days [9], 4 to 10 days [9, 11], or less than 10 days [10]. After the tenth postinjury day, clotted blood was reportedly difficult to remove, and adhesions prevented lung collapse [8, 11]. Successful evacuation has been reported as late as postinjury day 8 [12], day 15 [13], and day 35 [13].

Subsequent to the above analysis, a further two studies addressing thoracoscopy and retained hemothoraces with a total of 49 patients has been reported. Vassiliu and associates [14], in a series of 24 patients with residual hemothorax, successfully performed thoracoscopic evacuation in 22 of their patients (92%). Their recommendation was to perform VATS ideally within 3 days of injury. The reasons given for conversion to thoracotomy in 2 patients was inadeaquate double lumen intubation in 1 patient, and dense adhesions preventing lung deflation in the other. The latter patient was operated on 6 days after injury. In a prospective randomized trial, Meyer and colleagues [15] investigated the early evacuation of traumatic retained hemothoraces using thoracoscopy versus second tube thoracostomy. They found that early intervention (< 48 hours) with VATS may be more efficient and economical for managing retained hemothoraces. Posttraumatic empyema managed by VATS has been reported in a collective review of 30 patients, culled from six studies, to have been successful in 19 of 22 patients (86%) [5]. The mean postinjury day of operation varied among studies, which reported 4, 10.3, and 23.7 days. A retrospective study by Scherer and coworkers [16] successfully managed 16 of 22 patients (72.7%) with posttraumatic empyema, and concluded VATS to be a safe and effective operative strategy.

The use of intrapleural fibrinolysis with streptokinase and urikinase as an adjunctive treatment in hemothorax and empyema is well documented with success rates ranging from 62.5% [17] to 92% [18]. We have no experience with this procedure and are presently reviewing the available literature to assess the feasibility of performing a prospective study. More than 50% of patients in this series had two or more attempts at tube drainage and 44 patients (96%) were referred from surrounding hospitals. This resultant delay in referral had many patients presenting with semiclotted blood, adhesions from pleural inflammatory reaction, and empyema. To overcome the problems of not achieving complete lung deflation with double-lumen intubation and adequate thoracoscopic visualization, a direct surgical approach to the retained hemothorax was adopted. The position of the loculated collection was determined from CT scans of the chest or lateral chest radiographs. It is currently our policy to perform a spiral CAT scan of the chest in all patients with significant residual opacities on chest radiographs to delineate the total geometry of loculated collections and to differentiate among consolidation or atelectasis, contusion, intrapulmonary collection, pleural collection, and pleural reaction. Skin incisions for port placement were made directly over the loculated collections. These were then directly entered into, using the camera and suction catheter, and the pleural fluid evacuated. The adherent lung was thus freed from within the cavity that contained the retained fluid. This operative strategy proved successful in 27 patients (76%) undergoing VATS evacuation, thereby avoiding a significant number of thoracotomies.

In summary, we conclude that thoracoscopy can be safely and effectively used to evacuate residual posttrauamitic hemothoraces. An early "window" period for successful thoracoscopic evacuation of retained posttraumatic hemothoraces is not universally applicable and of limited utility in decision making. It appears that pleural infection correlates with open treatment. The decision to proceed to thoracotomy can be rapidly based on the findings of VATS, and does not unduly prolong the procedure nor require a second trip to the operating room. A direct approach to the pleural fluid collection, as described, can be attributed to our successful outcome.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We would like to thank Freedom Gumedze, MS, from the Department of Statistical Sciences, University of Cape Town (Cape Town, South Africa), for his support and assistance with the statistical analyses.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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