Trauma pneumonectomy revisited: the role of simultaneously stapled pneumonectomy

Trauma pneumonectomy: A narrative review

PURPOSE

Thoracic injuries are common in both blunt and penetrating trauma. Most thoracic injuries are managed non-operatively, approximately 7-20% undergo thoracotomy. Of the injuries requiring thoracotomy, 1-6% ultimately require pulmonary resection. Wedge resection and lobectomies are well-studied in the literature; however, there is a paucity regarding reports on total pneumonectomy in the setting of trauma. Our objectives were to summarize the evidence supporting the role of trauma pneumonectomy (TP) in the current era and reiterate that despite the associated morbidity and mortality TP is justified in selective cases.

METHODS

A review of the world's literature was conducted following standard guidelines. Inclusion criteria included those studies reviewing blunt and penetrating trauma to the lungs in adults (age greater than 15 year) that reported mortality rates and outcome measures.

RESULTS

The PubMed search yielded 713 studies. Of these, 14 studies included pertinent information on TP. Studies included in this review were published from 1985 to 2017 and involved patient data that was collected from 1972 to 2014. Mortality ranged from 50% to 100% (median 63%; mean 68%).

CONCLUSION

In the setting of severe thoracic trauma, pulmonary resection may be necessary. Less aggressive techniques are options in a stable patient; however, in the setting of ongoing hemorrhage, TP should be considered and expediently conducted. The role of damage control thoracic surgery and related techniques is vitally important in these patients to improve the significant mortality of trauma pneumonectomy.

Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: A content analysis and expert appropriateness rating study

BACKGROUND

The use of abbreviated or damage control (DC) interventions may improve outcomes in severely injured patients when appropriately indicated. We sought to determine which indications for DC interventions have been most commonly reported in the peer-reviewed literature to date and evaluate the opinions of experts regarding the appropriateness (expected benefit-to-harm ratio) of the reported indications for use in practice.

METHODS

Two investigators used an abbreviated grounded theory method to synthesize indications for 16 different DC interventions reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. For each indication code, an international panel of trauma surgery experts (n = 9) then rated the appropriateness of conducting the DC intervention of interest in an adult civilian trauma patient.

RESULTS

The 424 indications identified in the literature were synthesized into 101 unique indications. The panel assessed 12 (70.6%) of the coded indications for the 7 different thoracic, 47 (78.3%) for the 7 different abdominal/pelvic, and 18 (75.0%) for the 2 different vascular interventions to be appropriate for use in practice. These included indications for rapid lung-sparing surgery (pneumonorrhaphy, pulmonary tractotomy, and pulmonary wedge resection) (n = 1); pulmonary tractotomy (n = 3); rapid, simultaneously stapled pneumonectomy (n = 1); therapeutic mediastinal and/or pleural space packing (n = 4); temporary thoracic closure (n = 3); therapeutic perihepatic packing (n = 28); staged pancreaticoduodenectomy (n = 2); temporary abdominal closure (n = 12); extraperitoneal pelvic packing (n = 5); balloon catheter tamponade (n = 6); and temporary intravascular shunting (n = 11).

CONCLUSION

This study identified a list of candidate appropriate indications for use of 12 different DC interventions that were suggested by authors of peer-reviewed articles and assessed by a panel of independent experts to be appropriate. These indications may be used to focus future research and (in the interim) guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.

Damage-control techniques in the management of severe lung trauma

BACKGROUND

Damage control (DC) has improved survival from severe abdominal and extremity injuries. The data on the surgical strategies and outcomes in patients managed with DC for severe thoracic injuries are scarce.

METHODS

This is a retrospective review of patients treated with DC for thoracic/pulmonary complex trauma at two Level I trauma centers from 2006 to 2010. Subjects 14 years and older were included. Demographics, trauma characteristics, surgical techniques, and resuscitation strategies were reviewed.

RESULTS

A total of 840 trauma thoracotomies were performed. DC thoracotomy (DCT) was performed in 31 patients (3.7%). Pulmonary trauma was found in 25 of them. The median age was 28 years (interquartile range [IQR], 20-34 years), Revised Trauma Score (RTS) was 7.11 (IQR, 5.44-7.55), and Injury Severity Score (ISS) was 26 (IQR, 25-41). Nineteen patients had gunshot wounds, four had stab wounds, and two had blunt trauma.Pulmonary trauma was managed by pneumorrhaphy in 3, tractotomy in 12, wedge resection in 1, and packing as primary treatment in 8 patients. Clamping of the pulmonary hilum was used as a last resource in seven patients. Five patients returned to the intensive care unit with the pulmonary hilum occluded by a vascular clamp or an en masse ligature. These patients underwent a deferred resection within 16 hours to 90 hours after the initial DCT. Four of them survived.Bleeding from other intrathoracic sources was found in 20 patients: major vessels in nine, heart in three, and thoracic wall in nine.DCT mortality in pulmonary trauma was 6 (24%) of 25 because of coagulopathy, or persistent bleeding in 5 patients and multiorgan failure in 1 patient.

CONCLUSION

This series describes our experience with DCT in severe lung trauma. We describe pulmonary hilum clamping and deferred lung resection as a viable surgical alternative for major pulmonary injuries and the use of packing as a definitive method for hemorrhage control.

LEVEL OF EVIDENCE

Epidemiologic study, level V.

Pulmonary lobar root clamping and stapling technique: return of the "en masse lobectomy"

PURPOSE

Most thoracic surgeons have experienced difficulty dissecting the pulmonary hilus because of scarring. In such potentially dangerous situations, we advocate a method of clamping and severing the pulmonary lobar root structure en masse. The aim of this study was to evaluate en masse lobectomy, particularly considering the constellation of pulmonary vessels and the bronchus.

METHODS

Twelve patients (median age 70 years) underwent en masse lobectomy. We retrospectively evaluated the surgical procedures and clinical outcomes. Care was taken to consider the remaining vessels and bronchus, which regulate the direction of device placement.

RESULTS

Seven patients had inflammatory lung disease, four had primary pulmonary carcinoma, and one had suffered blunt chest trauma. Ten operations were elective and two were emergent. Lobectomy included the right upper lobe in two cases, the right middle lobe in three, the right lower lobe in two, the right middle-lower lobe in two, and the left lower lobe in three. A stapler was used in ten patients, and sutures were applied in three (both were used in one case). Morbidities included a pyothorax and a persistent air leak; both made a recovery. Mortality included one emergency case of acute respiratory distress syndrome. No bronchopleural or bronchovascular fistulas occurred.

CONCLUSIONS

We believe that the en masse lobectomy is an alternative and necessary technique in critical or unexpected situations, possibly as a last resort. Trauma and severe inflammation may be good indications for en masse lobectomy.

Porcine traumatic lung injury model induced by hilum clamping

OBJECTIVE

To establish a temporary pulmonary hilum clamping model for thoracic damage control surgery, as well as to determine the safety time latitude of this manipulation.

METHODS

Pigs were anaesthetised and instrumented with a thermodilution cardiac output catheter. The left pulmonary hilum was clamped with a urethral catheter after thoracotomy, maintained for three different time periods (n=6 for each group), 90min (C90), 120min (C120) and 150min (C150) and then unclamped. Haemodynamic data were recorded and the serum samples were collected for D-dimer detection and other haematological analysis. A 1-cm(3) pulmonary tissue of the left lower lobe was also obtained for histological study before clamping, at the end of clamping and at 0.5, 1, 1.5, 2 and 4h after unclamping.

RESULTS

Postoperative survival rate in each group of the pigs was as follows: 100% (all six) of C90, 83.3% (five of six) of C120, and 33.3% (two of six) of C150. Blood pressure (BP) and heart rate (HR) increased after clamping and gradually declined after unclamping. The animals of C150 group suffered highest BP and HR, respiratory index, pulmonary dynamic compliance and cardiac output. Platelet count showed no significant changes between the C90 and C120 groups, whereas a decline was noticed in the C150 group. Pulmonary vascular resistance increased significantly after pulmonary hilum clamping; when unclamped, there were minor changes in animals of C90 and C120 groups while there was a persistent elevation in the C150 group. An elevated D-dimer was detected in the C150 group, whereas it was normal in the C90 and C120 groups. There was significantly serious inflammatory cell infiltration, perivascular oedema and haemorrhagic infiltration in the C150 group compared with the C90 and C120 groups.

CONCLUSIONS

We established a pulmonary hilum clamping animal model for investigating pulmonary damage. By studying the haemodynamic and lung function changes of three different unilateral pulmonary hilum clamping time, it was determined that 120min was the longest safety time for hilum clamping without lethal pulmonary injury in porcine models.

Avaliação eletrocardiográfica em cães submetidos à pneumonectomia direita

O propósito das ressecções pulmonares em cães e gatos, quer sejam por lobectomia ou pneumonectomia, é a cura ou paliação de processos broncopulmonares sempre que os meios conservadores de tratamento clínico sejam considerados ineficientes. Tendo em vista as significativas alterações resultantes da pneumonectomia, novos estudos experimentais devem ser feitos para avaliar as vantagens dessa intervenção cirúrgica e determinar a maneira como aplicá-la com segurança. O presente estudo tem como objetivo avaliar as alterações eletrocardiográficas em dez cães adultos de ambos os sexos, sem raça definida, com 10-30 kg, submetidos à pneumonectomia direita. Foram avaliados diariamente os parâmetros clínicos de cada cão e as alterações em todas as derivações do eletrocardiograma. Todos os cães apresentaram um bom desenlace pós-operatório. Apenas um cão apresentou alteração de relevância clínica, um caso de complexos ventriculares prematuros, possivelmente decorrente da parada cardiorrespiratória, que foi revertido com sucesso. Houve diminuição da amplitude dos complexos QRS nos primeiros 14 dias, retornado ao normal após 60 dias de pós-operatório.

EMERGENCY THORACIC SURGERY FOR PENETRATING, NON-MEDIASTINAL TRAUMA

BACKGROUND

Penetrating thoracic injury is commonly found in South Africa. A review of our recent experience was undertaken to assess the effectiveness of our protocols for this type of injury.

METHODS

A retrospective study of 61 consecutive patients with penetrating, non-mediastinal trauma to the chest was conducted over 32 months at a single trauma unit. Patient details, mechanism of injury, operative procedure and in-hospital mortality and morbidity rates were recorded.

RESULTS

Two thousand and nineteen patients presented with penetrating chest injury of which 61 patients (3%) underwent thoracic surgery for non-mediastinal injury. Twenty-six patients had stab wounds and 35 had gunshot wounds. Overall mortality was 17/61 (28%). Gunshot wounds were more likely to result in death than stab wounds (relative risk = 11.9; 95% confidence interval 1.7-84.0) and thoracoabdominal injury resulted in death more commonly than chest injury (relative risk = 4.8; 95% confidence interval 2.2-10.3) resulted in death.

CONCLUSION

Penetrating chest injury is common and most patients can be managed without formal thoracic surgical intervention. However, the patients who do merit surgical intervention have a relatively high mortality and a rapid and practised operative approach is required to achieve acceptable results.

Thoracic trauma: when and how to intervene

Trauma is the leading cause of death in patients younger than 40 years of age. Thoracic injuries are common and often can be managed by tube thoracostomy. In many patients, however, the thoracic injuries must be repaired surgically in one of three time periods: immediate, urgent, or delayed thoracotomy. In this article, we describe the general approach to effectively managing thoracic trauma patients. We review common injuries and scenarios that may be encountered by the surgeon and discuss the considerations and variables that enter into the decision-making process for operative intervention.

Damage control surgery for thoracic injuries

Damage control of thoracic injuries begins frequently with an emergency department thoracotomy via an anterolateral incision. Bleeding and air leaks are quickly temporised. As opposed to abdominal damage control where most injuries can be temporised, most thoracic injuries require initial definitive repair. Thus, the goal of thoracic damage control is to perform the least definitive repair using the fastest and easiest techniques to shorten the operative time as much as possible. There are some injuries that can be temporised and require re-operation once physiologic normality has been achieved.

The pulmonary hilum twist as a thoracic damage control procedure

BACKGROUND

Damage control techniques have been developed and applied to abdominal, vascular and thoracic injuries. Thoracic damage control techniques must be rapid and simple.

METHODS

This report describes the successful use of pulmonary hilum twist as an effective damage control technique to control hemorrhage for severe lung trauma.

RESULTS

The procedure involves division of the inferior pulmonary ligament then anterior rotation of the lower lobe over the upper lobe. The technique can be utilized in multiple settings including the emergency center, operating room, and during resuscitation. When vascular occlusion is maintained throughout resuscitation in the intensive care unit, pneumonectomy most likely will be required, but can be performed when the physiologic parameters have improved. Complications are similar to pneumonectomy and can include right-side heart failure, dysrrythmias, and hypoxia.

CONCLUSIONS

Pulmonary hilar twist is an effective technique that should be considered when a damage control approach is needed.

Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury

BACKGROUND

Emergency lung resection following penetrating chest trauma has been associated with mortality rates as high as 55-100%. Pulmonary tractotomy is advocated as a rapid alternative method of dealing with deep lobar injuries. We reviewed our experience with resection and tractotomy to determine whether method of management affects mortality or if patient presentation is more critical in determining outcome.

METHODS

A retrospective review of all patients with chest injury seen at an urban Level I trauma center from 2/89-1/99 was performed. All patients undergoing parenchymal surgery were included. Records were abstracted for grade of injury, type of resection, presenting systolic blood pressure (SBP), temperature, Injury Severity Score (ISS), operative time, and estimated blood loss (EBL). Mortality and thoracic complications were compared between groups.

RESULTS

Two hundred forty-six of 2736 patients with penetrating chest trauma underwent thoracotomy, with 70 (28%) requiring some form of lung resection. There were 11 (15.7%) deaths. Patients who died had lower SBP (53 +/- 32 mm Hg vs 77 +/- 28 mm Hg), lower temperature (32.5 degrees +/- 1.3 degrees C vs 34.3 degrees +/- 1.2 degrees C), higher ISS (33 +/- 13 vs 23 +/- 9), and greater EBL (9.8 +/- 4.3 liters vs 2.8 +/- 2.1 liters) compared with survivors (p < 0.05 for all). Mortality was also increased in the presence of cardiac injury (33% with vs 12% without) and the need for laparotomy (26% with vs 9% without) (p < 0.05 for all). Tractotomy was associated with an increased incidence of chest complications (67% vs 24%, p = 0.05) compared with lobectomy with no difference in presenting physiology, operative time, or mortality.

CONCLUSION

Lung resection for penetrating injuries can be done safely with morbidity and mortality rates lower than previously reported. Patient outcome is related to severity of injury rather than type of resection. Tractotomy is associated with a higher incidence of infectious complications and is not associated with shortened operative times or survival.

Management of traumatic lung injury: a Western Trauma Association Multicenter review

BACKGROUND

Improved outcomes following lung injury have been reported using "lung sparing" techniques.

METHODS

A retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as "minor" (suture, wedge resection, tractotomy) or "major" (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded.

RESULTS

One hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores "minor" 3.8 +/- 0.9 vs. "major" 4.3 +/- 0.7, p = 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4-2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality.

CONCLUSION

Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.

Advances in the diagnosis and treatment of thoracic trauma

With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade or hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using beta-blocker-induced relative hypotension, is rapidly becoming the standard of care throughout the United States.