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Ann Thorac Surg 1997;64:1396-1400
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Early Evacuation of Traumatic Retained Hemothoraces Using Thoracoscopy: A Prospective, Randomized Trial

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Failure to adequately evacuate blood from the pleural space after trauma may result in extended hospitalization and complications such as empyema.

Methods. Patients with retained hemothoraces were prospectively randomized to either a second tube thoracostomy (group 1, n = 24) or video-assisted thoracoscopy (VATS) (group 2, n = 15). Group 1 patients in whom additional tube drainage failed were subsequently randomized to either VATS or thoracotomy. Study end points included duration and costs of hospitalization.

Results. During a 4-year period, 39 patients were entered into the study. Patients in group 2 had shorter duration of tube drainage (2.53 ± 1.36 versus 4.50 ± 2.83 days, mean ± standard deviation; p < 0.02), shorter hospital stay after the procedure (3.60 ± 1.64 versus 7.21 ± 5.30 days; p < 0.02), and shorter total hospital stay (5.40 ± 2.16 versus 8.13 ± 4.62 days; p < 0.02). Hospital costs were also less in this group ($7,689 ± 3,278 versus $13,273 ± 8,158; p < 0.02). There was no mortality in either group. No group 2 patient required conversion to thoracotomy. In 10 group 1 patients additional tube placement failed, and this subset was randomized to VATS (n = 5) or thoracotomy (n = 5). No significant difference in clinical outcome was found between these subgroups.

Conclusions. In many patients treated only with additional tube drainage (group 1), this therapy fails, necessitating further intervention. Intent to treat with early VATS for retained hemothoraces decreases the duration of tube drainage, the length of hospital stay, and hospital cost. Early intervention with VATS may be a more efficient and economical strategy for managing retained hemothoraces after trauma.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 1400.

Failure to adequately 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 [1]. Additional tube placement is simple and inexpensive, but may be ineffective, leading to additional procedures or a prolonged hospital course. In contrast, thoracotomy is effective, but remains invasive and associated with potential morbidity. Video-assisted thoracoscopy (VATS) now provides another option for managing this problem. This less invasive technique may allow more complete initial evacuation of traumatic hemothoraces, thereby reducing or preventing pleural space complications. Improved drainage may be accomplished by endoscopically guided thoracostomy tube placement or by detecting the cause of incomplete evacuation of the hemothorax. This prospective, randomized study was performed to better define the role of this increasingly used technique by comparing two strategies for managing retained hemothoraces after chest trauma: (1) placement of an additional thoracostomy tube, and (2) early treatment with VATS.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Patients
Thirty-nine patients seen at Parkland Memorial Hospital between April 1992 and June 1996 with retained hemothoraces after thoracic trauma were prospectively randomized into this study. Approval for this protocol was obtained through the institutional review board of the University of Texas Southwestern Medical Center at Dallas on December 4, 1991. All patients had been treated with placement of a 36F straight thoracostomy tube at the time of initial evaluation. Patients were considered for the study if chest roentgenogram showed a retained hemothorax or hemopneumothorax within 72 hours of the initial thoracostomy tube placement. Patients with minimal costophrenic angle blunting were excluded. Those included in the study were hemodynamically stable, had no significant associated intraabdominal injuries, or were stable patients recovering from repaired injuries. All patients were older than 15 years of age, and none had previous thoracotomy on the side of injury. Patients were excluded from the study if they were hemodynamically unstable, had greater than 1,500 mL of blood on placement of initial tube thoracostomy, or had ongoing blood loss of greater than 250 mL/h.

Patients were randomized into one of two groups based on initial management strategy: group 1, placement of a second tube thoracostomy; or group 2, VATS. Characteristics of each group are shown in Table 1. Patients assigned to group 1 who demonstrated persistent retained hemothorax after placement of the second chest tube were subsequently randomized to receive either thoracoscopy or thoracotomy. The decision to perform the additional procedure was made immediately after the chest radiograph taken after insertion of the second thoracostomy tube. The subsequent intervention was then performed at the next available elective operating room time. On weekends, it was performed during nonpeak operating room hours. Thoracoscopy included VATS techniques, typically using one to two 5- or 10-mm ports in addition to the tube thoracostomy site. A double-lumen endotracheal tube was used in all cases. Ports were positioned to accommodate potential conversion to thoracotomy (Fig 1). No insufflation was used. Thoracotomy consisted of a limited lateral incision, with extension as guided by the extent of injury. One or two drainage tubes were used after VATS or thoracotomy. After either procedure, thoracostomy tubes were removed at the discretion of the trauma team who endeavored to meet the following criteria: minimal drainage (less than 80 mL/8 h) and no air leak. Patients in all groups received perioperative cefuroxime, which was continued for 24 to 48 hours after the procedure.

View larger version (21K): [in this window] [in a new window]   Fig 1. . Patient positioning and thoracoscopic port placement for potential conversion to thoracotomy.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Thirty-nine patients qualified for the study. There were 35 men and 4 women, with ages ranging from 15 years to 57 years (mean, 29.3 years). The mechanism of injury was penetrating in 33 patients and blunt in 6 patients. Of the 33 patients with penetrating injuries, 19 had gunshot wounds, 12 had stab wounds, and 2 had shotgun injuries (Table 1). Randomization placed 24 patients in the tube thoracostomy group (group 1) and 15 patients in the thoracoscopy group (group 2). The time to initial randomization averaged 42 hours from hospital presentation. Group 1 patients in whom additional tube placement failed (n = 10) were subsequently randomized to either VATS (n = 5) or thoracotomy (n = 5). This secondary randomization usually occurred immediately after examination of the postprocedure chest roentgenogram.

Intent to Treat Analysis
Patients initially randomized to VATS (group 2) had a significantly shorter duration of chest tube drainage (2.53 ± 1.36 versus 4.50 ± 2.83 days, mean ± standard deviation; p < 0.02), and remained in hospital fewer days after the procedure (3.60 ± 1.64 versus 7.21 ± 5.30 days; p < 0.02) (Table 2). One patient in Group 1 had a total hospital stay (39 days) that was more than four standard deviations greater than the mean of the group. This data point was excluded. Despite this, total hospitalization remained shorter in group 2 (5.40 ± 2.16 versus 8.13 ± 4.62 days; p < 0.02).

Subgroup Analysis
No patient in group 2 required conversion to thoracotomy. However, 10 patients in group 1 failed the placement of an additional tube thoracostomy and were randomized either to VATS (n = 5) or thoracotomy (n = 5). As shown in Table 3, there were no significant differences in the duration of tube drainage, hospital days after procedure, total hospital days, and hospital costs between these two subsets.

In the entire series there was no mortality. Atelectasis developed in 5 patients, as determined by chest roentgenogram before hospital discharge. All patients had undergone VATS (2 from group 2, and 3 from group 1 who required this additional procedure). Additionally, after final removal of tube thoracostomy, three recurrent pneumothoraces and two recurrent hemothoraces developed, all in Group 1 patients and all requiring further intervention. At 6-month follow-up, no empyema or fibrothorax was identified in any patient.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
This study suggests that early use of VATS for retained hemothoraces after chest trauma may have substantial benefits compared with conventional therapy. Significant reductions in the duration of tube thoracostomy drainage, hospital stay after the procedure, overall hospitalization, and hospital costs were found in patients undergoing VATS drainage as initial therapy for this problem. The use of VATS facilitates rapid and complete evacuation of the pleural space, exploration of the cavity to assess for evidence of ongoing bleeding, and video-assisted positioning of the thoracostomy tubes to optimize drainage. These advantages promote early tube removal, which may translate to lower hospital stays and reduced costs.

Comparison of the duration of chest tube drainage of the two treatment strategies illustrates this benefit of thoracoscopy in the trauma setting. The goals of acute intervention in cases of retained hemothoraces include rapid removal of residual clot without having to wait for hematoma liquefaction, identification of the source or persistence of bleeding, and detection and treatment of other injuries in the thorax. When all these goals are met, the thoracostomy tube can be removed with confidence either in the recovery room or the following day, facilitating early patient discharge. The ability of VATS to achieve these objectives may explain the reduced duration of drainage in the group who underwent initial thoracoscopy compared with the group with thoracostomy tubes only. Also, the shorter duration of tube thoracostomy drainage may translate to a significantly more abbreviated hospital stay after the procedure, a shorter total hospitalization, and reduced hospital cost (Table 2).

Clearly, initial tube thoracostomy is successful in the majority of patients who present with uncomplicated hemothorax after trauma. During a 4-year period at Parkland Memorial Hospital, approximately 1,600 patients were treated for various forms of chest trauma. About one third of these patients (597) presented with hemothoraces or hemopneumothoraces. Of these patients, about 4% had a retained hemothorax or subsequent empyema. Coselli and colleagues [1] found retained hemothoraces after tube thoracotomy placement in less than 4% of 4,766 patients presenting with traumatic hemothorax or pneumohemothorax. This 18.5-year retrospective study included 39 patients who underwent early evacuation of retained hemothorax by thoracotomy with an average total hospital stay of 10 days. Early evacuation was performed without mortality and was advocated to decrease hospital stay and to avoid empyema or fibrothorax, which carried higher morbidity and mortality rates.

The use of thoracoscopy in the management of trauma is not a new concept. In 1946, Branco [2] used thoracoscopy to aid in the diagnosis and treatment of patients with penetrating injury to the chest. He coagulated bleeding vessels in 5 patients, eliminating the need for thoracotomy. Later studies have reported the use of the thoracoscope to assess patients after penetrating thoracic trauma, significantly reducing the need for thoracotomy [3–5]. However, not until the introduction of modern laparoscopy into the trauma setting [6–8] did thoracic surgeons begin to reassess the thoracoscope for traumatic applications [9]. Recent reports have supported the utility of videothoracoscopy for diagnosis. Ochsner and associates [10] used thoracoscopy to correctly evaluate 14 patients for diaphragmatic injury. They also found that VATS enabled the evacuation of retained hemothoraces and provided excellent visualization of intrathoracic structures. In a similar study, Uribe and colleagues [11] prospectively evaluated 28 patients with thoracoabdominal penetrating trauma by VATS. Although their study focused on the utility of VATS for identification of diaphragmatic injury, they also noted it to be useful for evacuation of blood from the pleural space.

Early experiences with VATS in the management of hemothoraces have been reported as parts of other studies. Smith and associates [12] assessed 24 consecutive patients with chest trauma thoracoscopically for clotted hemothorax. Successful evacuation was performed in 8 of 9 patients. Five patients were treated for continued hemorrhage, with 3 of 5 managed thoracoscopically with diathermy. Landreneau and colleagues [13] used VATS in 23 patients with retained hemothoraces from various causes and recommended VATS early in the management of patients with retained hemothoraces to avoid the problems of secondary infection within the intrathoracic clot or late fibrothorax. A recent experience with VATS for management of retained hemothorax was reported by Heniford and associates [14]. In their series of 25 patients, 19 patients (76%) were successfully treated with VATS. Four patients (16%) were converted to open thoracotomy, and 2 (8%) required additional procedures to drain collections. Failure to achieve adequate operative treatment using thoracoscopy correlated with the time interval from injury to operation (successful, 4.5 days; unsuccessful, 14.5 days), and the type of collection (hemothorax versus empyema). Empyema did not develop in anyone operated on within 7 days of injury. These authors demonstrated excellent results in the patients in whom the procedure was completed and recommended VATS as the initial treatment for trauma patients with residual thoracic collections.

In this study we conducted a prospective, randomized trial assessing the use of VATS as a primary strategy for evacuation of retained hemothorax after trauma. Although VATS mandates a more expensive and complex initial approach, it results in reduced hospital stays and hospital costs. The group randomized to VATS saw a reduction of 2.7 days of hospitalization and nearly $6,000 in costs. Importantly, additional invasive procedures after the index intervention were completely avoided. These additional procedures contribute substantially to hospital costs.

In addition to the economic advantages seen with early evacuation of retained hemothoraces, prevention of late complications, such as empyema or fibrothorax, may also be realized. None of the 39 patients in the current study experienced these problems, a feature that may have been related to complete clearing of the pleural space. In a retrospective study, Eddy and associates [15] reported infectious complications (empyema) occurring in 5% of patients with thoracic trauma requiring emergent tube thoracostomy. Risk factors for the development of empyema included incomplete drainage of the pleural space and prolonged thoracostomy tube drainage, two features that were avoided in the VATS group in our study.

Although tube thoracostomy is appealing as a simple measure, complications, such as empyema, residual hemothorax or pneumothorax, improper tube positioning, complications after tube removal, and direct lung injuries, may occur in as many as 21% of patients [16]. Thoracoscopy is also not immune to complications, but reported complication rates in large series are less than 10% [17]. In our study, morbidity was present in both the tube thoracostomy and VATS groups. Recurrent pneumothoraces and hemothoraces may represent sequelae of missed (or iatrogenic) small lung parenchymal injuries in the tube thoracostomy group. Postoperative atelectasis may be related to splinting from pain after any of the procedures.

This study was limited by a number of factors. The size of the population was small, a reflection of the low incidence of retained hemothoraces after initial tube drainage. Our initial estimate of sample size needed to achieve statistical significance between groups was 90 patients, but interim analysis demonstrated significance after 39 patients. As a result, the study was terminated at this point. Randomization did not include a blocking factor to assure equal group sizes at this early time point, and as a result, the group sizes were different. Patients in group 1 were younger and had fewer associated injuries than those in group 2, but despite this had longer hospital courses. The group size precluded any meaningful multivariate analysis to test the effects of age or other prerandomization factors.

A long study accrual period (4 years in this case) was problematic, as patient care practices have changed over time, with efforts focused at reducing hospital stays. However, measures taken to facilitate earlier hospital discharge should have been directed equally toward both groups. Management of the thoracostomy tubes for both groups, specifically the decision to remove the tubes, was left to the discretion of the trauma team caring for the patients. No efforts were made to direct this decision, as that may have skewed the data toward one group or the other. The total number of hospital days was a difficult end point to evaluate, as several patients had major comorbidity unrelated to the thoracic trauma that prolonged hospitalization. Despite this, a shorter stay favoring early thoracoscopy was observed. Finally, as professional fees were not included in the analysis, it is possible that the cost differences favoring VATS may be overstated.

Based on these data, early thoracoscopic intervention should be considered for management of retained hemothoraces. Benefits include abbreviated thoracostomy tube drainage, shorter hospital stay after the procedure, shorter overall hospitalization, and decreased total cost. Using this technique, complete evacuation of the clotted hemothorax is expected, as well as full expansion of the affected lung. Under direct visualization, further exploration of the pleural cavity is possible, potentially allowing for control of hemorrhage in a hemodynamically stable patient, as well as direct positioning of the thoracostomy tubes. Moreover, early evacuation may decrease the complications associated with retained hemothoraces, such as empyema formation and fibrothorax. As experience expands with the use of thoracoscopy in carefully selected trauma settings, this technology may provide our patients with newer diagnostic and therapeutic options in a safe, efficient, and cost-effective manner.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We are grateful to Ethicon Corp. for supplying a portion of the trochars used in performing the thoracoscopic procedures and the Departments of Medical Records and Accounting/Finance of Parkland Health & Hospital System for their assistance with this project.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.

Address reprint requests to Dr Meyer, Division of Thoracic and Cardiovascular Surgery, University of Texas, Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 75235-8879 (e-mail: dmeyer{at}mednet.swmed.edu).

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments 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): Dan M. Meyer Michael E. Jessen Michael A. Wait Aaron S. Estrera Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Meyer, D. M. Articles by Estrera, A. S. Search for Related Content PubMed PubMed Citation Articles by Meyer, D. M. Articles by Estrera, A. S. Related Collections Related Article