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Thoracoscopic Evacuation of Retained PosttraumaticHemothoraxPradeep H. Navsaria, FCS(SA),MMed(Surg), Richard J.Vogel, FCS(SA), andAndrew J.Nicol, FCS(SA)Department of Surgery, Trauma Unit, Groote Sehuur Hospital and the Faeulty of Health Scienees, University of Cape Town, CapeTown, South Afriea

Background. Residual posttraumatie hemothoraees oe-eur in 1% to 20% of patients managed with tube thora-eostomy. Video-assisted thoraeoseopie surgery (VATS)has emerged as an altemative to thoraeotomy to evaeuatethese retained eollections. This report reviews a recenttrauma unit experience with thoracoscopic evacuation ofhemothoraces.

Methods. The records of all trauma patients undergo-ing surgical intervention for retained hemothoraces overthe 30-month period January 2001 to June 2003 werereviewed.

Results. The study included 46 patients. All sustainedpenetrating injuries, 40 with stab and 6 with gunshotwounds. Twenty-two, 17, and 7 patients each had one,two and three attempts at drainage with tube thoracos-tomy, respectively. In 37 patients (80%), retained infect-edluninfected pleural fluid was successfully evacuated

Inadequately drained posttraumatic hemothorax withtube thoracostomy can lead to the complications of

fibrothorax/entrapped lung or empyema. Convention-ally, these conditions are managed surgically with openthoracotomy. Video-assisted thoracoscopic surgery(VATS) has emerged as an aItemative surgical techniquein the evaluation and treatment of posttraumatic pleuralcomplications. Notably, retained hemothoraces havebeen successfully evacuated and are currently indicatedas one of the most suitable conditions amenable tothoracoscopic surgery. We report on our experience, anddescribe our thoracoscopic technique used in the evacu-ation of posttraumatic retained hemothoraces.

Patients and Methods

Over the 30-month period January 2001 to June 2003 therecords of all patients with posttraumatic retained pleu-ral collections that underwent surgical evacuation werereviewed. Patients with clotted hemothoraces, and thosewith a suspected or proven infected pleural collection,were identified for thoracoscopic evaluation and man-agement. A clotted hemothorax was defined as a residual

Accepted for publication Nov 21, 2003.

Address reprint requests to Dr Navsaria, Trauma Unit-C14, GrooteSchuur Hospital, Anzio Rd, Observatory 7925, Cape Town, South Africa;e-mail: navsaria@uctgshl.uct.ac.za.

@ 2004 by The Society of Thoracie SurgeonsPublished by Elsevier Ine

thoracoscopically. VATS failed in 9 (20%) patients andthe procedure was converted to open thoracotomy. Denseadhesions were present in all 9 of these patients. Themean time interval between injury and thoracoscopy andthoracotomy, was 13.3 days (range 3-46 days) and 14.5days (range 11-24 days), respectively. The mean volumeof pleural fluid evacuated thoracoscopically was 650 mL.The failure of VATS evacuation correlated with theempyema rate. The median postoperative stay was 5 daysfor both groups.

Conclusions. Video-assisted thoracoscopic surgery isan accurate, safe, and reliable operative therapy forretained posttraumatic pleural collections, even in pa-tients presenting later than the conventionally accepted3- to 5-day window from the time of injury.

(Ann Thorac Surg 2004;78:282-6)@ 2004 by The Society of Thoracic Surgeons

clot estimated to be larger than 500 mL or that occupiedat least one third of the involved hemithorax. An infectedthoracic collection was defined as a bacteriologicallyproven infection of any colIection in the pleural space,documented before or after surgery. Patients with per-sistent opacities (> 33% involvement of a hemithorax) onchest radiograph and those with persistent opacities withsigns of intrathoracic sepsis (fever, raised white celIcount, purulent drainage) were evaluated with a thoracicspiral computed axial tomography (CAT) scan. Patientswith residual opacities with multiple air-fluid levels orlocalized run-off on lateral decubitus chest radiographswith failure to drain with tube thoracostomy underwentsurgery without a thoracic computed tomographic (CT)scan. In the operating room, all patients underwentgeneral anesthesia with double lumen endotracheal in-tubation. AlI patients were administered intravenousantibiotic combination of amoxicillin and clavulinic acidperioperatively. This was continued for a maximum of 24hours. Thereafter, therapy was directed according tomicroscopy, culture, and sensitivity resuIts. Empyemaswere managed with 4 weeks of oral antibiotic adminis-tration and sterile cuItures (ie, presence of white bloodcells [WBC] and no organisms) with l-week oral amoxi-cillin and claviulinic acid, and those with no WBC and noculture with 24-hour postoperative intravenous amoxicil-lin and calvulinic acid only. Patients were placed in thecorresponding fulllateral decubitus position to facilitate

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conversion to a posterolateral thoracotomy if required.Standard thoracoscopy equipment was used, including ascope with a zero-degree angle with 16X magnificationand a xenon light source, and a single high-resolutionvideo monitor. No positive-pressure insufflation wasused. A 2-cm incision was placed directly over the site ofthe loculated colIection as determined from the CT scanor lateral chest radiograph. A suction catheter was in-serted into the pleural cavity, into the loculated colIec-tion, and as much of the pleural fluid removed. Pleuralfluid was sent for microbiologic assessment. A 10-mmtrocar with the telescope was introduced into the locu-lated cavity. Another 2-cm incision was placed 8 to 10 cmaway from the initial incision, along the same intercostalspace, and the suction catheter was introduced throughthis incision. Further evacuation of the pleural contentswas performed under direct vision with the camera. Ringforceps was used to remove rind from the visceral andparietal pleura. Gentle dissection under direct visionwith sponge sticks and ring forceps released the trappedlung. Thus, the procedure was performed from withinthe loculated colIection, gently releasing the adherentlung from the chest walI toward normal lung. Once alIthe pleural fluid and fibrin was evacuated, adequate lungexpansion was observed by ventilating the ipsilaterallung. Two thoracostomy tubes were placed postopera-tively into the port sites; one into the previous loculatedcavity and another directed toward the apex. AlI patientswere transferred to a high-care unit where both intercos-tal drains were placed onto low-pressure suction. A chestradiograph was obtained, blood for arterial blood gastaken, and routine monitoring of vital signs performed.AlI patients received physiotherapy twice daily. Chesttubes were removed once pleural drainage was less than50 mL or when the air leak had stopped for 12 hours. Thestatistical package STATA 7.0 (Stata Statistical Software,Release 7.0; Stata Corporation, ColIege Station, TX) wasused to conduct statistical analysis. The difference inmedians and proportions was tested using the Mann-Whitney and the Z-test, respectively. Statistical signifi-cance was defined as p less than 0.05.

Results

Of the 1054 patients admitted during the study periodrequiring or admitted with tube thorocostomy, therewere 46 patients (4.4%) with a retained pleural colIection.Of note, is that 44 patients (96%) were referred with asuspected retained thoracic colIection from neighboringhospitaIs. Only 2 patients initialIy managed in the unitdeveloped a residual hemothorax resulting in a 0.2%residual hemothorax rate. There were 40 men and 6women with a mean age of 29.3 years old (range 18 to 49years old). AlI patients sustained a penetrating injury,with stab and gunshot wounds accounting for 40 and 6 ofthe retained colIections, respectively. Before referral, 22,17, and 7 patients each had one, two, and three attemptsat pleural fluid drainage with tube thoracostomy, respec-tively. The 2 patients managed initialIy in the unit had asingle tube drainage procedure only. Thirty-two patients

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had a spiral CAT scan of the chest illustrating a loculated,retained pleural colIection. The remaining 14 patientshad residual opacities on chest radiograph with multipleair-fluid levels or run-off on lateral decubitus chest ra-diographs with failed attempts to drain with tube thora-costomy. Thoracoscopic evacuation of the pleural fluidwas successful in 37 patients (80%)and 9 patiens (20%)required conversion to standard thoracotomy.

Analysis of Thirty-Seven Patients UndergoingSuccessful VATS Evacuation

Only 6 patients were afebrile at the time of surgery. Theremaining 31 had a mean fever of 38.4°C (range 37.8-39.9°C). The mean time from injury to thoracoscopy was13.3 days (range 3 to 46 days), with a median of 10 days.lnadequate lung deflation under general anesthetic withdouble lumen endotracheal intubation occurred in 28patients (76%) in this group. The mean operative timewas 62.6 minutes (range 30-85 minutes), and the meanvolume of retained fluid evacuated was 678 mL (range300-1700 mL). The bacteriologic profile of the pleuralfluid determined from intraoperative pus swab resultswere: 19 patients (51.4%) had no white celIs, no organ-sims, and negative culture after 72 hours; 9 patients(24.3%) had positive white celIs, no organisms, and neg-ative culture after 72hours; and 9patients (24.3%)had anempyema. Empyema pleural fluid culture results re-vealed 6 patients with Staphylococcalaureus,1 patient withStreptococcus sanguines, 1 with mixed organisms, and 1patient with three Gram-negative organisms (Bacilluscereus, Klebsiella pneumoniae, and Acinetobacter species).FulIlung expansion was visualized in alI patients intra-operatively and confirmed with postoperative chest ra-diographs. Two patients sustained iatrogenic minor lunglacerations during the VATS procedure. These were leftalone and did not adversely influence hospital stay ortube thoracostomy remova!. Tube thoracosotmy was re-moved at a median of 4 days (range 2-9 days). Themedian postoperative stay was 5 days (range 3-12 days).There were no recurrences of pleural fluid at 2- and6-week clinical and radiologic folIow-up.

Analysis of Nine Patients Requiring Conversion toThoracotomy

Severe pleural inflammatory reaction resulting in denseadhesions, thus precluding camera insertion and VATSevacuation, was the main reason to convert to thoracot-omy. AlI except 1 patient was febrile with a meantemperature of 38.5°C (range 37.5-39.3°C). The white celIcount was raised in alI patients with a mean of 18.3 celIsmL3 (range 14 to 30.6 celIs mL3). The mean time delayfrom injury to thoracotomy was 14.5 days (range 11-24days), with a median of 12 days. The mean volume offluid recovered at thoracotomy was 738 mL (range 100-3000 mL). The macroscopic appearance of the pleuralfluid was purulent in 8 patients and bloody in the other.The bacteriological profile was as folIows: 7 empyemas (6with S. aureus, 1 with Klebsiellapneumoniae), and 2 sterilepurulent colIections (positve white celIs and no cultureafter 72 hours). FulIlung expansion was visualized in alI

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patients intraoperarively and confirmed with postopera-tive chest radiographs. One patient developed superficialwound sepsis of the thoracotomy wound. This was man-aged with suture removal and dressings as an outpatient.Tube thoracosotmy was removed at a median of 3 days(1-7 days) in 8 patients. One patient with an empyemahad the tube thoracostomy cut short and a drainage bagapplied for persistent purulent drainage. This was re-moved at 2-week follow-up. The residual draining sinuseventually closed approximately 7 weeks after surgery.There was no recurrence of clinical or radiologic evi-dence of empyema or pleural fluid at 2- and 6-weekfollow-up. The median postoperative stay was 5 days(range 3-28 days).

Apart from dense adhesions precluding access to thepleural cavity and conversion to thoracotomy (100%), thefailure of VATS evacuation correlated with the bacterio-

logic assessment of the pleural fluidoThe empyema ratewas lower in the thorocoscopy group compared with thethoracotomy group, 24.3%(95%confidence interval [CI]50-100) and 78% (95% CI 10-38), respectively. This dif-ference in proportion was statistiscally different (p =0.0013).The failure of VATS evacuation did not correlatewith the median time elapsed from injury to surgery: 12days for thoracotomy versus 10 days for thoracoscopy (p= 0.139). The median postoperative stay in the twogroups was the same, 5 days, and not statistically differ-ent (p = 0.132). The median time to tube thoracostomyremoval in the thoracotomy and thoracoscopy groupswas 3 and 4 days, respectively, and not significantlydifferent (p = 0.137).

Comment

Retained hemothorax reportedly occurs in 1% to 20% ofpatients with chest trauma [1]. Using a protocol based onvigorous physiotherapy and early withdrawal of tubethoracostomy in 1845 patients, retained hemothorax andempyema rates of 2.7% and 0.5%, respectively, werereported by Knottenbelt and associates [2] from ourtrauma unit. The complications of entrapped lung andempyema following inadequately drained pleural bloodhas traditionally been managed by thoracotomy. Coselliand coworkers [3] reported a study that strongly supportsearly drainage in such cases. They reviewed 4000 patientsrequiring chest tube for hemothorax. A thoracotomy wasnecessary for 3.8% of patients for fibrothorax and empy-ema. The mortality for early evacuation « 5 days) was0% compared with mortality rates of 1.6% and 9.4% forpatients who progressed to decortication or empyema,respectively.

Video-assisted thoracoscopic surgery (VATS) has beenrevitalized with the advent of improved imaging technol-ogy and the evolution of endoscopic instrumentation.The current role of VATS in trauma includes evaluation

and control of continued chest tube bleeding, earlyevacuation of retained hemothorax, evacuation and de-cortication of posttraumatic empyemas, evaluation andlimited treatment of suspected diaphragm injuries, eval-

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uation and treatment of persistent air leaks, and evalua-tion of mediastinal injuries [4].

The use of VATS in the early evacuation of posttrau-matic retained hemothorax has been well documented.

Villavicencio and colleagues [5],in a review analyzing therole of thoracoscopy in retained hemothorax, identifiedeight studies with a total 99 patients [6-13]. Evacuationby VATS was successful in 89 of 99 patients (90%). Meanpostinjury day to operation varied among the studies,and ranged from 4.3 to 10.8 days. Technical failuresduring VATS evacuation occurred as a result of poorvisualization from incomplete lung deflation, dense ad-hesions, or clotted blood. Despite the 10% failure rate, alIthe studies recommended early VATS evacuation toavoid complications of fibrothorax and empyema. Sev-eral of the authors described a window period for theVATS evacuation of less than 3 days [9], 4 to 10 days [9,11], or less than 10 days [10]. After the tenth postinjuryday, clotted blood was reportedly difficult to remove, andadhesions prevented lung collapse [8, 11]. Successfulevacuation has been reported as late as postinjury day 8[12], day 15 [13], and day 35 [13].

Subsequent to the above analysis, a further two studiesaddressing thoracoscopy and retained hemothoraceswith a total of 49 patients has been reported. Vassiliu andassociates [14], in a series of 24 patients with residualhemothorax, successfully performed thoracoscopic evac-uation in 22 of their patients (92%). Their recommenda-tion was to perform VATS ideally within 3 days of injury.The reasons given for conversion to thoracotomy in 2patients was inadeaquate double lumen intubation in 1patient, and dense adhesions preventing lung deflationin the other. The latter patient was operated on 6 daysafter injury. In a prospective randomized trial, Meyer andcolleagues [15] investigated the early evacuation of trau-matic retained hemothoraces using thoracoscopy versussecond tube thoracostomy. They found that early inter-vention « 48 hours) with VATS may be more efficientand economical for managing retained hemothoraces.Posttraumatic empyema managed by VATS has beenreported in a collective review of 30 patients, culled fromsix studies, to have been successful in 19 of 22 patients(86%) [5]. The mean postinjury day of operation variedamong studies, which reported 4, 10.3, and 23.7 days. Aretrospective study by Scherer and coworkers [16] suc-cessfully managed 16 of 22 patients (72.7%) with post-traumatic empyema, and concluded VATS to be a safeand effective operative strategy.

The use of intrapleural fibrinolysis with streptokinaseand urikinase as an adjunctive treatment in hemothoraxand empyema is well documented with success ratesranging from 62.5% [17] to 92% [18].We have no experi-ence with this procedure and are presently reviewing theavailable literature to assess the feasibility of performinga prospective study. More than 50% of patients in thisseries had two or more attempts at tube drainage and 44patients (96%) were referred from surrounding hospitaIs.This resultant delay in referral had many patients pre-senting with semiclotted blood, adhesions from pleuralinflammatory reaction, and empyema. To overcome the

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problems of not achieving complete lung deflation withdouble-Iumen intubation and adequate thoracoscopicvisualization, a direct surgical approach to the retainedhemothorax was adopted. The position of the loculatedcollection was determined from CT scans of the chest orlateral chest radiographs. It is currently our policy toperform a spiral CAT scan of the chest in alI patients withsignificant residual opacities on chest radiographs todelineate the total geometry of loculated collections andto differentiate among consolidation or atelectasis, con-tusion, intrapulmonary collection, pleural collection, andpleural reaction. Skin incisions for port placement weremade directly over the loculated collections. These werethen directly entered into, using the camera and suctioncatheter, and the pleural fluid evacuated. The adherentlung was thus freed from within the cavity that containedthe retained fluido This operative strategy proved suc-cessful in 27 patients (76%) undergoing VATS evacua-tion, thereby avoiding a significant number ofthoracotomies.

In summary, we conclude that thoracoscopy can besafely and effectively used to evacuate residual post-trauamitic hemothoraces. An early "window" period forsuccessful thoracoscopic evacuation of retained posttrau-matic hemothoraces is not universally applicable and oflimited utility in decision making. It appears that pleuralinfection correlates with open treatment. The decision toproceed to thoracotomy can be rapidly based on thefindings of VATS, and does not unduly prolong theprocedure nor require a second trip to the operatingroom. A direct approach to the pleural fluid collection, asdescribed, can be attributed to our successful outcome.

We would like to thank Freedom Gumedze, MS, from theDepartment of Statistical Sciences, University of Cape Town(Cape Town, South Africa), for his support and assistance withthe statistical analyses.

References

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2. KnottenbeIt JD, van der Spuy JW. Traumatic haemothorax-

INVITED COMMENT ARY

The approach to fibrinous-gelatinous material in thepleural space that cannot be drained by tubes andcatheters is an issue about which only a thoracic surgeoncan get excited. Further, it regrettably seems that, withsome exceptions, only thoracic surgeons understand thenuances of "space problems" and "trapped lung." Thepotential consequences of undrained material are pleuralspace infection due to the original process or to ourinterventions, and parietal or visceral diminution of thepleural space (fibrothorax, trapped lung) that preventslung expansion to a degree that interferes with breathing.This subject is a good example of the art of medicine, as

(Q 2004 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

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experience of a protocol for rapid turnover in 1845 cases. 5Afr J Surg 1994;32:5-8.

3. Cosem JS, Mattox KL, Beall AC Jr. Reevaluation of earlyevacuation of cIottedhemothorax. Am J Surg 1984;148:786-90.

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8. Lang-Lazdunski L, Mouroux J, Pons F, et aI. Role of video-thorocoscopy in chest trauma. Ann Thorac Surg 1997;63:327-33.

9. Liu DW, Liu HP, Lin PJ, Chang CH. Video-assisted thoracicsurgery in treatment of chest trauma. J Trauma 1997;42:670-4.

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it is greatly case-dependent and is difficult to quantify.The result is that spaces are often termed pneumothora-ces, radiographs rather than patients become the focus ofwell-intentioned discussion, and clinical decisions are

thereby muddled by terminology and technology.The report of Navsaria and colleagues examines their

experience with VATS assessment and treatment of onesource of retained pleural collections-posttraumatic he-mothorax. Although the lessons from this paper are notunique, the findings deserve emphasis. The main pointsare interrelated. Most importantly, the authors foundthat an early "window" period for successful video-

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