Ann Thorac Surg 1997;63:1587-1588
© 1997 The Society of Thoracic Surgeons
Original Article: General Thoracic
Pulmonary Resection for Lung Trauma
Kenneth C. Stewart, MD,
John D. Urschel, MD,
Someshwar S. Nakai, MB, BS,
Elliot T. Gelfand, MD,
Stewart M. Hamilton, MD
Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
Accepted for publication December 26, 1996.
 |
Abstract
|
|---|
Background. Pulmonary resection is rarely required for trauma, and its mortality is reportedly high.
Methods. A 10-year retrospective review of pulmonary resections for trauma was done.
Results. Of 2,455 patients with chest trauma, 183 (7.4%) underwent thoracotomy and 32 (1.3%) required pulmonary resection. Mean age was 28.4 years and mean injury severity score was 24.5. Mechanism of injury was stab wound in 14 patients, gunshot wound in 6, and blunt trauma in 12. Blunt trauma patients had a higher injury severity score (29.6) than penetrating trauma patients (21.4), but this was not significant (p < 0.07). Indications for thoracotomy were hemorrhage in 24 patients, airway disruption in 4, and other indications in 4. Operations consisted of wedge resection (19 patients), lobectomy (9), and pneumonectomy (4). Four (12.5%) patients (pneumonectomy, 2; lobectomy, 1; wedge, 1) died. Mortality for pneumonectomy was 50%, but this was not significantly higher than for lesser resections. Blunt trauma had a higher mortality (33%) than penetrating trauma (0%) (p < 0.02). Nonsurvivors had higher injury severity scores (44.2) than survivors (21.6) (p < 0.001).
Conclusions. Pulmonary resection is infrequently required for lung injury. Overall mortality is lower than previously reported, but pneumonectomy has a high mortality. Blunt trauma has a higher mortality than penetrating trauma. Injury severity scores are higher for nonsurvivors than survivors; this shows the importance of associated injuries on outcome.
|
Introduction
|
|---|
The vast majority of chest trauma patients are successfully managed with tube thoracostomy and general supportive measures [1]. Thoracotomy is infrequently required, and pulmonary resection is seldom needed. Several trauma centers have reported a high mortality for pulmonary resection for lung trauma [2–5]. We reviewed our experience with pulmonary resection in this setting and compared it with previous reports.
|
Material and Methods
|
|---|
A 10-year (1985–1994) review of pulmonary resections for lung trauma was done at two regional trauma centers. The University of Alberta and the Royal Alexandra hospitals, in Edmonton, Alberta, Canada, provide trauma care to approximately 900,000 residents of Edmonton and northern Alberta. Charts were reviewed for mechanism of injury, associated injuries, treatment, and outcome. Statistical analysis (Statsoft, Tulsa, OK) for nonparametric data was done with Fisher's exact probability test and parametric data was analyzed with the two-tailed Student's t test. A p value less than 0.05 was taken to indicate significance. Injury severity score data are presented as means ± standard deviation.
|
Results
|
|---|
Two thousand four hundred fifty-five patients were treated for chest trauma in the 10-year study period. Of these, 183 (7.4%) patients underwent thoracotomy and 32 (1.3%) required pulmonary resection. These 32 patients form the study population for this review. There were 26 men and 6 women. Mean age was 28.4 years. Mechanism of injury was stab wound in 14, gunshot wound in 6, and blunt trauma in 12 patients. Mean injury severity score was 24.5. Blunt trauma patients had a higher injury severity score (29.6 ± 16.5) than penetrating trauma patients (21.4 ± 8.5), but this was not significant (p < 0.07). Associated injuries were present in 21 patients (abdominal, 9; skeletal, 9; neurologic, 5; cardiac, 2; other, 5).
Thoracotomy was done within 24 hours of admission in 26 patients, and after 24 hours in the other 6 patients. Indications for early thoracotomy were hemorrhage in 23 patients and airway disruption in 3. In the 6 patients having late thoracotomy, indications were sepsis (2 patients), prolonged air leak (2), persistent bleeding (1), and delayed recognition of bronchial disruption (1 patient). Overall, operations consisted of 19 wedge resections, 9 lobectomies, and 4 pneumonectomies. Mean duration of postoperative mechanical ventilation was 7 days for blunt injury and gunshot wounds, and less than 1 day for stab wounds. Mean hospital length of stay was 27 days for blunt injury, 22 days for gunshot wounds, and 6 days for stab wounds.
Four (12.5%) patients (pneumonectomy, 2; lobectomy, 1; wedge, 1) died. Two of the nonsurvivors died within 24 hours of operation of overwhelming associated injuries (combined abdominal and neurologic). The other 2 patients, both of who underwent pneumonectomy, died 26 and 175 days after injury; these deaths were caused by sepsis and multiorgan system failure. Mortality for pneumonectomy was 50%, but this was not significantly higher than for lesser resections. Blunt trauma had a significantly higher mortality (33%) than penetrating trauma (0%) (p < 0.02). Nonsurvivors had a significantly higher injury severity score (44.2 ± 14.4) than survivors (21.6 ± 9.6) (p < 0.001).
|
Comment
|
|---|
Pulmonary resection is infrequently required for lung trauma [1]. Only 1.3% of our chest trauma patients underwent lung resection; this finding confirms the results of others [4]. In relatively stable patients we favor a posterolateral thoracotomy, because of the advantages it provides for exposure of the lung and hilum. A double-lumen endotracheal tube is beneficial if hemoptysis is present; this helps to prevent contamination of the dependent lung by blood. In unstable patients, with either hypotension or marked hemoptysis, it is safer to quickly intubate with a single-lumen endotracheal tube and do an anterolateral thoracotomy [6]. The adverse effects of the lateral position on venous return, and contamination of the contralateral lung, are thereby avoided.
Like other investigators [2, 4, 6], we believe that early clamping of the hilum is advisable in any patient with a central lung injury, or massive bleeding of undetermined origin. Hilar clamping quickly controls hemorrhage, prevents air embolism, and allows determination of extent of injury [6]. A decision can then be made regarding the advisability of repair or resection, and the extent of resection needed. Peripheral lung injuries can usually be repaired. However, we have been liberal in our use of stapled wedge resection for these peripheral lung injuries. Central injuries and extensive pulmonary lacerations require lobectomy or pneumonectomy.
Previous reports of pulmonary resection for lung trauma have shown a high mortality, especially for pneumonectomy. Most researchers report an overall mortality of more than 30%, and a pneumonectomy mortality of more than 50% [2–5]. Our experience has been more favorable, with an overall mortality of 12.5%. In part, this low mortality could reflect our use of stapled wedge resection for peripheral lung injuries. This relatively favorable group of patients may have been managed by repair in other reports; a higher reported mortality for pulmonary resection would result.
Pneumonectomy had a high mortality in this series (50%). However, we did not encounter the dramatic acute cardiopulmonary sequelae of pneumonectomy, namely, right ventricular failure and shock, which have been reported by others [3, 7]. We have no explanation for this, but our limited experience with pneumonectomy for trauma (4 patients) precludes us from drawing any conclusions. Our two deaths after pneumonectomy were caused by late sepsis and multiorgan failure. In fact, the causes of death in this series of chest trauma patients parallel that of trauma patients in general; they die early of overwhelming injuries to vital organs, or succumb much later to sepsis and multiorgan system failure.
Blunt trauma had a significantly higher mortality than penetrating trauma in this series; other investigators have not reported this finding. Subjectively, we have the impression that our blunt trauma patients are more severely injured than penetrating trauma patients, but statistical analysis of injury severity scores does not show a statistical difference. Further data from American trauma centers on this point would be valuable. The demographics of trauma and trauma care are different in Canada and the United States [8], and our finding may not apply to the American trauma experience.
Mortality in this series was related to the magnitude of injury as indicated by the injury severity score. Despite timely and aggressive management of chest injuries, death often results from associated massive intraabdominal and neurologic injuries.
|
Footnotes
|
|---|
Address reprint requests to Dr Urschel, Division of Thoracic Surgery, Roswell Park Cancer Institute, Elm and Carlton St, Buffalo, NY 14263-0001.
|
References
|
|---|
- Pickard LR, Mattox KL. Thoracic trauma general considerations and indications for thoracotomy. In: Moore EE, Mattox KL, Feliciano DV, eds. Trauma, 2nd ed. Norwalk: Appleton & Lange, 1991:319–26.
- Hankins JR, McAslan TC, Shin B, Ayella R, Cowley RA, McLaughlin JS. Extensive pulmonary laceration caused by blunt trauma. J Thorac Cardiovasc Surg 1977;74:519–27.[Medline]
- Bowling R, Mavroudis C, Richardson JD, Flint LM, Howe WR, Gray LA. Emergency pneumonectomy for penetrating and blunt trauma. Am Surg 1985;51:136–9.[Medline]
- Thompson DA, Rowlands BJ, Walker WE, Kuykendall RG, Miller PW, Fischer RP. Urgent thoracotomy for pulmonary or tracheobronchial injury. J Trauma 1988;28:276–80.[Medline]
- Tominaga GT, Waxman K, Scannell G, Annas C, Ott RA, Gazzaniga AB. Emergency thoracotomy with lung resection following trauma. Am Surg 1993;59:834–7.[Medline]
- Wiencek RG, Wilson RF. Central lung injuries: a need for early vascular control. J Trauma 1988;28:1418–24.[Medline]
- Cryer HG, Mavroudis C, Yu J, et al. Shock, transfusion and pneumonectomy: death is due to right heart failure and increased pulmonary vascular resistance. Ann Surg 1990;212:197–201.[Medline]
- Hill AB, Fleiszer DM, Brown RA. Chest trauma in a Canadian urban setting-implications for trauma research in Canada. J Trauma 1991;31:971–3.[Medline]
This article has been cited by other articles:
|
|
|
|
 
R. Karmy-Jones, G. J. Jurkovich, A. B. Nathens, D. V. Shatz, S. Brundage, M. J. Wall Jr, S. Engelhardt, D. B. Hoyt, J. Holcroft, and M. M. Knudson
Timing of Urgent Thoracotomy for Hemorrhage After Trauma: A Multicenter Study
Arch Surg,
May 1, 2001;
136(5):
513 - 518.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
