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Ann Thorac Surg 2007;83:383-387
© 2007 The Society of Thoracic Surgeons
Department of General Thoracic Surgery, Rambam Medical Center, Haifa, Israel
Accepted for publication September 25, 2006.
* Address correspondence to Dr Ben-Nun, Department of General Thoracic Surgery, Rambam Medical Center, Haifa 31096, Israel. (Email: a_ben_nun{at}rambam.health.gov.il).
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Abstract |
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METHODS: Medical records of patients with chest trauma during a 10-year period were reviewed. The study included 77 patients (37 patients in the VATS group and 40 in the thoracotomy group). Forty-four patients who underwent operative treatment during the study period were excluded from the study. Hospital charts and a telephone questionnaire were used to evaluate the outcome.
RESULTS: No deaths occurred in either group. Clotted hemothorax was the most common finding. The incidence of wound and pulmonary complication were higher in the thoracotomy group. Patients in the thoracotomy group needed significantly higher doses of narcotic analgesia. Average time to resume normal activity was shorter in the VATS group. More than 2 years after discharge, the rate of return to a normal lifestyle was 81% in the VATS group and 60% of the thoracotomy group. Patients in the VATS group were generally more satisfied with their health status and surgical scars.
CONCLUSIONS: The results of this study show that for stable patients with chest trauma, video assisted thoracic surgery is feasible and safe. Moreover, it is tolerated better than open thoracotomy, has a favorable postoperative course, a superior long-term outcome, and greater patient satisfaction.
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Introduction |
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In the last decade, the advent and increasing expertise in video-assisted thoracic surgery (VATS) has made it an attractive alternative in the management of hemodynamically stable patients with chest injury. Several articles have discussed the indications, feasibility, and safety of VATS and demonstrated good results [6–11]. Very few have addressed the long-term benefits of VATS in this subgroup of patients. In this study, we compared the outcome of VATS versus anterolateral thoracotomy in stable patients with chest trauma. We assessed the short-term and the long-term outcome, with an emphasis on the patient’s perspective.
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Patients and Methods |
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Data Collection and Inclusion Criteria
The hospital computerized registration and records were used to identify and categorize this group of patients. The Institutional Review Board approved the study. The inclusion criteria were:
Before operation, all patients underwent a complete imaging evaluation, including plain chest roentgenogram, a computed tomography (CT) angiography scan of the chest, and abdominal assessment with CT scan, ultrasound imaging, or both.
The decision to perform VATS or anterolateral thoracotomy was made by the personal preference of the attending thoracic surgeon on call. One team performed thoracotomy, and the other, the VATS procedure. Ten patients were excluded from the study because the decision to perform thoracotomy was not based on the attending surgeon’s preference but on specific imaging findings, including massive pericardial effusion, esophageal perforation that included a large diaphragmatic rupture with abdominal viscera in the chest, and suspected spillage of gastric content.
Operative Technique: Thoracotomy Group
The operation was performed in a standard fashion under general anesthesia using a single lumen endotracheal tube. Patients were placed in a prone position with the side to be operated on slightly elevated, and an anterolateral thoracotomy in the 4th intercostal space was performed using a rib-spreading retractor. At the end of the procedure, two chest tubes were placed anterior and posterior to the lung, and the surgical wound was closed using pericostal polypropylene sutures.
Operative Technique: VATS Group
The operation was performed under general anesthesia. A double-lumen endotracheal tube was used in 34 patients (85%). A lateral decubitus position was used in 28 patients (70%), and 12 were operated on in a prone position with the side to be operated on slightly elevated. The video equipment was placed on both sides of the patient’s head. A 10-mm 30-degree scope (Karl Storz, Tuttlingen, Germany) was used in all cases.
In the 85% of patients with a chest tube, that incision was always used to introduce the first thoraco-port. In patients with penetrating trauma, we used the wounds as working ports (but not as the first one). The number of ports, the size, and the location were determined by the operative finding. In most cases, three ports were used. In 4 patients, a 4-cm utility incision, without rib spreading, was used to insert the working tools.
Postoperative Care
All patients were extubated and observed for 3 to 4 hours in the recovery room. During this time, the chest tubes were connected to low-pressure suction (–5 cm H2O) to reduce residual pleural space and prevent early blood clot formation. Afterwards, the chest tubes were maintained under water seal without negative pressure.
Postoperative analgesia included combination of intravenous (IV) morphine, given in as a patient control analgesia (IV-PCA), and oral dipyrone. After cessation of IV-PCA, patients were treated with oral tramadol (200 mg daily) and dipyrone (4 g daily). Intramuscular injections of morphine were given according to the visual analogue pain scale (0, no pain; 10, intractable pain) and at the patient’s request.
Chest tubes were removed after a 24-hour period with no air leak, less than 150 mL of fluid discharge, and a complete expansion of the lung. Patients were discharged after tube removal and were established on pain management using tramadol, dipyrone, and oral opiates (oxycodone) as needed.
Postoperative Follow-Up
After discharge from the hospital, routine follow-up was scheduled at 1 week, 2 weeks, 1 month, 3 months, and then annually. The mean follow-up period was 46 ± 7.5 months (range, 12 to 58 months) and was similar in both groups. Twelve patients (4 in the VATS and 8 in the thoracotomy group) were lost to long-term follow-up and were excluded (Table 1).
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Long-term cosmetic results
Patients were asked to score their satisfaction with the operative scars from 1 to 5, in which 1 was very unsatisfied, 2 was unsatisfied, 3 was acceptable, 4 was satisfied, and 5 was very satisfied.
Normal activity score
Patients were asked to define the recovery period to completely normal activity with 1, than 3 months; 2, 4 months; 3, more than 6 months; 4, more than a year; and 5, did not have a complete recovery.
Data Analyses
The demographic and relevant clinical information were retrospectively collected from the hospital records. Data included operative findings and duration, complications, pain scores, requested doses of narcotic medications, length of tube drainage, and length of hospital stay. Out-patient clinic documentation and a telephone questionnaire were used to collect the long-term follow-up data, including pain scores, need for analgesics or pain clinic service, return to normal activity and lifestyle, evaluation of patients’ satisfaction, and cosmetic result. Continuous variables such as age, operation time, length of hospitalization, and morphine doses were expressed as mean ± standard deviation and analyzed by the two-sample t test.
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Results |
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Demographic Data
Table 2
summarizes the demographic data. The average age was 26 years (range, 16 to 54 years) in the VATS group and 25 years (range, 15 to 60 years) in the thoracotomy group, and 74 patients were males (95% in the VATS group and 97% in the thoracotomy group). In 3 patients, VATS was converted to open thoracotomy because of bleeding in 2 and severe intrapleural adhesions in 1. These patients were included in the thoracotomy group.
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Early Postoperative Course
The early postoperative data are summarized in Table 3. No surgery-related deaths or major morbidity occurred in either group. In postoperative days (POD) 1 and 2, the PCA morphine doses were similar in both groups, but starting at POD 3, patients in the VATS group required significantly lower doses of morphine and other narcotic medications compared with the thoracotomy group.
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Average length of hospitalization was shorter in the VATS group at 6 ± 2 days compared with 8 ± 3 in the thoracotomy group (p < 0.05). On hospital discharge, oral opiate analgesia was required in 90% of the thoracotomy patients and in 54% of the VATS group (p < 0.05). At 3 months after discharge, 68% of the VATS group but only 15% of the thoracotomy group had returned to normal activity.
Long-Term Results
More than 2 years after the injury (average, 31 months), 92% of the VATS-treated patients were pain free compared with 50% of the thoracotomy group; 33% of the patients in the thoracotomy group and 3% in the VATS group (p < 0.05) were using analgesics more than once monthly. Eighty-nine percent of VATS patients and 45% of the thoracotomy patients considered themselves "fully recovered, and 81% of the VATS group and 60% of the thoracotomy returned to their normal lifestyle. Patients that underwent VATS were significantly more satisfied with their general health status and with the cosmetic results of their surgery (Table 4).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Anterolateral thoracotomy was, and still is, the most popular incision used in the treatment of patients with chest trauma. This incision, by itself, may cause a prolonged recovery period and severe morbidity even in patients with mild intrathoracic injury. The reported incidence of chronic postthoracotomy pain syndrome is between 5% and 25% [4, 5].
In the last decade, VATS has provided an alternative method to simultaneously diagnose and manage patients with chest injuries. Navsaria and colleagues [12] reported their positive experience with VATS treatment for retained hemothorax. Manlulu and colleagues [13] and other authors [6–14] reviewed the literature and reported their personal experience. Many of the VATS procedures in these studies were not performed in the acute phase but a few days after the trauma. The authors focused mainly on the feasibility and safety of the operation and the short-term results. Most studies verify the safety of VATS and the favorable early recovery.
In this article, we report a 10-year single institution experience with stable patients undergoing VATS or thoracotomy for blunt and penetrating chest injuries. Although not prospective and not randomized, this study reflects properly the daily reality at a level I trauma center. Two teams of thoracic surgeons use two diverse techniques to take care of stable patients with chest injury. The same routine protocol for postoperative treatment and outpatient clinic follow-up applies to patients from both groups.
VATS was successfully performed in 37 patients. In 3 patients, it was converted to open procedure. There was no mortality or major morbidity. Operative procedures included evacuation of clotted hemothorax, hemostasis of intrathoracic bleeders, repair of diaphragm, pulmonary tractotomy, wedge resection, or suture repair of the lung.
The results reported here are in agreement with earlier reports, but there are few differences that should be discussed further. All of our patients underwent early intervention in the acute phase, only a few hours after injury. This policy reduces the incidence of on-going bleeding and the need for blood products. It also prevents prolonged air leak, retained hemothorax, trapped lung, and empyema. As mentioned in the Methods section, we always use the chest tube incision as the first port for the initial video-assisted exploration. We also use the injury site as a working port in nearly all patients with penetrating trauma. There were no complications related to this technique.
These results demonstrate once again that in hemodynamically stable patients, VATS provides an accurate assessment of the intrathoracic damage and can be used effectively to manage most injuries. In this subgroup of patients, the conversion rate is fairly low and the early results are considerably better than with thoracotomy.
A much more important finding of this study, however, is the significantly superior long-term outcome. Most trauma patients are young and healthy and are expected to have many years of normal physical activity, including work and sports. Prolonged pain and sick leave have both psychologic and economic consequences and should be avoided as much as possible. More than 2 years after injury, 89% of the VATS group—but only 45% of the thoracotomy patients—considered themselves to be completely recovered, and only 60% of the thoracotomy group had returned to their normal lifestyle. It seems that this major difference between the groups stems from the added morbidity of the thoracotomy incision itself and not from the intrathoracic injury.
These data and a review of the literature confirm that in stable patients with chest trauma, VATS is feasible, safe, and carries a significant long-term benefit. We strongly believe that in the modern management of trauma, VATS should not be considered as a "luxury" but as an essential tool in the armamentarium of the trauma team.
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References |
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  S. R. Hazelrigg Invited commentary Ann. Thorac. Surg., February 1, 2007; 83(2): 387 - 387. [Full Text] [PDF]
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