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Ann Thorac Surg 1997;64:1400-1401
© 1997 The Society of Thoracic Surgeons
DR. GEOFFREY M. GRAEBER (Morgantown, WV):I congratulate Dr Meyer and his associates on a fine, prospective, randomized study that addressed the problem of retained hemothorax after chest trauma. I am grateful to them for providing me with a copy of their manuscript well in advance of the meeting.
The problem of retained hemothorax in patients suffering chest trauma is an important one, especially today when there is an emphasis on shortening hospital stays and diminishing hospital costs. In our experience, and in that of others, retained hemothorax after chest trauma often leads to fibrothorax or empyema. Both these conditions require subsequent surgical intervention for correction. Many of these patients require long hospitalizations with prolonged time in the intensive care unit. In more severe cases the patients may not be weaned from ventilators until surgical intervention to reexpand the afflicted lungs has been achieved.
Doctor Meyer and his associates have clearly shown that thoracoscopy, or VATS, is an effective, cost-efficient procedure to remove retained hemothoraces and clot after unsuccessful drainage using tube thoracostomy. Several of the points they have made require emphasis. The earlier the problem is addressed the easier it is to remove the clot. The patient should be prepared for a standard open thoracotomy as this procedure will be required in a minority of chest trauma patients, usually because of intraoperative recognition of a latent source of hemorrhage requiring direct attention for adequate control and repair. The chest ports should be placed, as Dr Meyer and his associates have noted, in accord with the proposed thoracotomy incision. It is important to note that VATS procedures allow for very precise placement of chest tubes.
The problem of patient accrual is a real one but is directly proportional to the time between injury and the placement of the first tube thoracostomy. In urban trauma centers in which this time is short, the number of trauma patients with retained hemothoraces will be fewer in any given year. In rural trauma centers in which the time between injury and the placement of the first chest tube may be longer, the yearly accrual of patients may well be higher. My colleagues and I are currently involved in a prospective, randomized study to evaluate retained hemothoraces at our university medical center, which has the only level I trauma center in West Virginia. The study is in its first year; hence the numbers remain small. No true inferences may be drawn at the present time, although some trends appear to be emerging.
I have two questions for Dr Meyer. Did the patients who had their hemothorax evacuated by VATS have significantly less drainage per day from their chest tubes than the patients having standard thoracotomies? Our experience with VATS for several different types of procedures has shown that intraoperative blood loss, duration of chest tube drainage, and daily amount of chest tube drainage is significantly less than for patients treated by standard thoracotomies. Operative time for VATS is generally shorter as well.
The second question is, did your patients wean from ventilators sooner after surgical evacuation of the retained hemothoraces than those patients treated with continued drainage? Our initial experience suggests that this is the case.
Again I congratulate Dr Meyer and his associates for an excellent study. I look forward to their continued contributions in the future, and I also thank The Society for the invitation to discuss this important paper.
DR MEYER: First of all, I thank Dr Graeber for taking the time to review and discuss my paper, and for his kind comments.
To address Dr Graeber's questions, let me preface my remarks by stating that the patients with persistent, retained hemothoraces who underwent the secondary randomization to VATS versus thoracotomy represent a small population. Their end points were subjected to analysis of variance, with the results as presented.
Regarding the question of the amount of tube drainage between VATS and thoracotomy groups, we did see a trend toward a decrease in the amount of tube drainage favoring the VATS group. The amount of thoracostomy tube drainage in the VATS group averaged 410 mL, whereas that of the thoracotomy group approached 900 mL before tube removal. The duration of tube drainage also tended to be shorter in the VATS group, specifically, 2.80 ± 1.92 days in the VATS group versus 4.20 ± 0.84 days in the thoracotomy group. Perhaps a larger patient population may have helped achieve statistical significance between these two groups. The surgical time differences between VATS and thoracotomy were slightly different, 54 minutes for the VATS and 72 minutes for thoracotomy.
Hospital days after the procedure did not differ between these two small subgroups, nor did total hospital length of stay or hospital costs. Again, we were limited in the subgroup analysis in our sample size. Our more powerful analysis, and our main focus of the study, was the intent to treat analysis, in which statistical significance at the p less than 0.02 level was found for these variables.
Regarding the question referring to intensive care unit stay and ventilator use, our patients were quite a different population from the ones seen in West Virginia. Most of our patients were not in the intensive care unit, with the majority suffering penetrating injuries. Patients described by Dr Graeber primarily had blunt chest trauma, a group often associated with many more problems as reflected by a typically lower injury severity score. Patients in our series were hemodynamically stable, had a minimum number of associated injuries, or were stable, recovering from repaired injuries. Therefore, none of our patients had problems getting extubated after the procedure, with extubation occurring primarily in the operating room.
We will be interested to see the results from Dr Graeber's randomized trial. I suspect that the study will support the use of early thoracoscopy to an even greater degree than our report given the patient population. Because of the prolonged transit time in the rural areas, initial tube thoracostomy placement will likely be successful to an even lesser extent than in our study because clot formation may be problematic. In our study, patients arrived in the emergency department much sooner after injury than would be expected in a rural setting.
One finding on which we did not elaborate was that successful initial treatment of hemothoraces, whether by thoracostomy tube placement or VATS, will decrease hospital length of stay and hospital costs. It is the additional procedure and prolonged hospital stays while waiting and deciding on the additional intervention that drive up costs. The problem is identifying which patients will respond to the initial simpler therapy—tube thoracostomy. Results from Dr Graeber's study may help provide the necessary information for this algorithm.
Related Article
Ann. Thorac. Surg. 1997 64: 1396-1400.
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