[Videothoracospy in thoracic trauma and penetrating injuries]

Contribution of videothoracoscopy in the management of thoracic wounds with diaphragmatic lesions: A single African center experience

Background and aims

The management of thoracic wounds induced by sharp objects outside an extreme emergency remains controversial. The means vary from exploratory thoracotomy to simple monitoring. Between these two extremes, videothoracoscopy as a means of exploration plays an important role and helps to avoid unnecessary thoracotomies, thus making it possible to make early diagnosis of diaphragmatic lesions. The aim of this study was to report our experience in videothoracoscopic management of thoracic wounds by penetrating objects.

Material and methods

From January 2010 to December 2015, 58 patients with an average age 22.5 years with a thoracic stab wound with a stable hemodynamic condition underwent videothoracoscopy.

Results

Thoracoscopy revealed a diaphragmatic injury in 17 patients, cardiac or pericardial wounds in four and a haemorrhagic pulmonary injury in 1; all were treated at video-assisted mini-thoracotomy. In the other 36 patients, videothoracoscopic exploration did not demonstrate any intra-thoracic lesion and the procedure consisted of aspiration of a residual hemothorax with the installation of a good view-controlled thoracic drainage. Hospital stay was between 48 and 72 h.

Conclusion

Videothoracoscopy is a safe and effective way to explore the thoracic cavity in patients with chest wounds with suspected diaphragmatic lesions. It avoids thoracotomy especially in hemodynamically stable patients.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

[The value of thoracoscopy in thorax trauma]

A hemodynamically stable patient presenting with persistent bleeding through his chest tube (ICD) is a classic indication for early thoracoscopic intervention in trauma. The source of bleeding and air leaks can be identified and often treated: bleeding and perforated pulmonary segments can be resected, and chest wall bleeding may be coagulated or sutured. Injuries to the diaphragm are difficult to diagnose, as they might not be seen in conventional trauma imaging without gross herniation of intra-abdominal contents into the thoracic cavity. Identifying the site of diaphragm perforation can give useful hints in thoracoabdominal trauma, identifying injured cavities and localizing the bullet or stab tract. Most often, diaphragmatic defects may be closed during diagnostic thoracoscopy as well. Non- or partially drainable hemothorax is another indication for thoracoscopy. Coagulated blood can be mechanically mobilised, and aspirated or primary bleeding may be stopped. Effective lavage and a high-performance suction device are required. Correct placement of the drainage is part of optimized therapy, along with inspection of all intrathoracic organs and surfaces. Furthermore, surgical and anaesthesiological teamwork and experience are prerequisites for the fast, professional application of a minimally invasive thoracoscopic approach in chest trauma patients. Diagnostically and theurapeutically, thoracoscopy plays an important role in the trauma setting--in the case of hemodynamically stable patients.

Videothoracoscopy versus intrapleural streptokinase for management of post traumatic retained haemothorax: a retrospective study of 65 cases

BACKGROUND

Post traumatic retained haemothorax (PRH) may cause pulmonary restrictions or septic pleural complications. Currently, minimally invasive procedures such as videothoracoscopy or intrapleural fibrinolysis have replaced open surgery in an effort to avoid these complications.

OBJECTIVE

We have reviewed retrospectively our use of videothoracoscopy versus intrapleural streptokinase for the management of PRH over the last 10 years.

PATIENTS AND METHOD

There were 56 males and nine females in the study. Thirty-one cases had been managed by intrapleural streptokinase (group I), and videothoracoscopy was performed on 34 cases (group II). Therapeutic results for both groups were determined by chest radiographs.

RESULTS

In the population from which we drew our study group, retained haemothoraces occurred in 10.9% of 596 cases with traumatic haemothorax. In group I, 22 patients had radiological improvement; the others underwent thoracotomy. In this group, mean hospitalisation time was 14.5(+/-4.2) days, and three cases were complicated by empyema. In group II, all patients except four had complete radiological improvement; two of them required a decortication. In this group, mean hospital stay was 9.8(+/-3.7) days. There were no deaths in either group. The differences between group I and group II for length of hospital stay and number of thoracotomies was statistically significant.

CONCLUSION

Videothoracoscopy is therefore a more effective procedure than intrapleural streptokinase for the management of PRH.

Traumatic lesions of the diaphragm. Our experience in 33 cases and review of the literature

We reviewed 33 consecutive patients with diaphragmatic injuries. Twenty-nine were admitted in emergency conditions after blunt (22 patients) or penetrating injury, presenting shock, dyspnoea, coma or acute abdomen in 21 cases; major associated lesions were found in 23 patients. Four patients presented acute complications of visceral herniation 2, 4, 84 and 216 months after the trauma. The diagnosis was preoperative in 23 cases, intraoperative in 9; in one case it was missed at laparotomy, becoming evident the day after. The sensibility of preoperative chest x-ray and CT was 86% and 100% in presence of visceral herniation, 14% and 0% in absence of visceral hernia. The diaphragmatic repair was always obtained by direct suture, following 20 haemostatic procedures (liver, spleen, mesenterium) and two bowel resections. The mortality rate was 24.4%; the morbidity rate was 48%. Traumatic lesions of the diaphragm are generally expression of particularly severe trauma whose outcome is mainly influenced by the associated lesions. They are also correlated to specific morbidity and mortality, so the surgical exploration is mandatory whenever this injury is suspected, considering that the preoperative diagnosis relies on visceral dislocation. Associated lesions influence the surgical strategy but a direct suture is usually effective in preventing specific complications.