S Kumar, Ramakant, A Rai, S Kumar, S Kumar, J Kumar, R Garg
hemothorax, thoracic trauma, video assisted thoracic surgery
S Kumar, Ramakant, A Rai, S Kumar, S Kumar, J Kumar, R Garg. evaluation of thoracoscopic management of thoracic trauma. The Internet Journal of Thoracic and Cardiovascular Surgery. 2008 Volume 14 Number 1.
Every individual in the world is at risk for traumatic injury. The etiologies of injury are as diverse as the lifestyles and socioeconomic backgrounds of its victims, ranging from interpersonal violence and terrorism to motor vehicle crashes and occupational accidents. Worldwide, an estimated 5 million people died as a result of injury in 2000, with a mortality rate of 83 per 100,000 of the population. (2).Of all the causes of traumatic injuries thoracic trauma is supposed to be the important reason of mortality and morbidity. The trend of high speed vehicular transport has worsen the situation in past 3-4 decades. In the United States alone 12 per million population per day - and 20-25% of deaths due to trauma are attributed to thoracic injury. Immediate deaths following traumatic injuries are usually due to major disruption of the heart or great vessels and early deaths due to thoracic trauma occurring within 30 minutes to 3 hours after the injury are usually secondary to cardiac tamponade airway obstruction and aspiration.Major anatomical structures which suffers injury following trauma are the chest wall, lungs and pleura, thoracic great vessels, diaphragm heart, trachea, bronchus and oesophagus. The magnitude of those problems and the significance of the associated injuries serve to underscore the importance of complete evaluation and timely intervention in the management of thoracic trauma.Video assisted thoracic surgery can be utilized as an effective and safe method for the initial diagnostic evaluation and surgical management of stable patients with penetrating thoracic trauma.The pleural cavity drainage with prolonged aspiration was the main treatment method for the patients with closed thoracic trauma and open trauma without organ injury. Lethality was 7.8% among all the patients and 12.9% among ones with thoracic penetrating wounds. There were no postoperative lethal outcomes. The rate of postoperative complications was 22.7%. Videothoracoscopy and video-assisted mini-thoracotomy are effective methods for diagnosis and treatment, reduce the rate of postoperative complications and lethal outcomes, limit the indications to wide thoracotomy.Only 10-15% of blunt trauma require thoracic surgery, and 15-30% of the penetrating chest trauma require open thoracotomy. 85% of patients with thoracic trauma, can be managed by simple lifesaving manoeuvre that do not require surgical treatment. 
The Present study was conducted on the patients with thoracic injuries (both blunt and penetrating) who presented to Trauma Center.in the department of General Surgery, C.S.M.M.U., Lucknow,India, from September 2007 to August 2008. Patients having Cardiac injuries, Great vessel injuries ,Tracheal injuries, Oesophageal injuries requiring exploratory laprotomy,thoracotomy, Head injury and major Orthopeadical injuries were excluded from the study.70 patients were randomized into two groups- Group - A VATS (Video assisted thoracic surgery) for hemodynamically stable patients. Group - B: ICD (Intercostal Drain)insertion only.VATS was done using 10mm zero degree, rigid operating telescope with a 5mm biopsy channel. Monopolar cautery was used for coagulation. The VATS was done with in 72 hrs of injury. Analysis OF PATIENTS was done in terms of
When assessed on subjective pain scoring method the patients in group – A had statistically significant pain relief on 7th post procedure day (p < 0.001). Pain relief in group – B on 7th post procedure days was also significant (p<0.001), but pain improvement is significantly higher in group – A on 3rd day and 7th day as compared to group – B (p=0.0262). Post procedure pain and discomforted was drastically reduce in group– A..(Tab1). When patients were assessed for dyspnea on NYHA - IV grading, the patients of thoracic injuries at the time of admission had grade – IV dyspnea in 88.6% in group – A and 97.14% in group – B which is not a statistically significant difference. After 7th day post procedure grade – IV dyspnea was present in none in group – A while in group – B 14.3% were having group – IV dyspnea. Improvement in dyspnea is significantly higher group – A than group – B on 7th post procedure day (p=0.05).(Tab2). Though radiological improvement in X-ray finding is significant in both group improvement is significantly higher and early in VATS than ICD group.(Tab3) The improvement by USG is significant in both groups but VATS shows early and more improvement than ICD.(Tab4). Due to reduced pain and discomfort, due to early and effective return of pulmonary function and due to early removal of chest drainage tube the patients in group- A were encouraged to go home early as compared to group – B. Median hospital stay in group – A was 8 days and group – B was 12th days(Tab5). There is significant increase in Pred. FEV1 at Post treatment in VATS and ICD.Increase in Pred. FEV1 is significantly higher ICD at post treatment. The rate of empyema, pneumonitis, superficial wound infections, organized hemothorax was significantly higher in group – A and than in group - B. Bronchopleural fistula formation and ventilator dependency is significantly higher in group – B than in group – A. (Tab6). CECT improvement is significantly higher in VATS groups than ICD group and early (at 3 days). (Tab7). There is significant increase in Pred. FVC at Post treatment in VATS and ICD.Increase in Pred. FVC is significantly higher VATS than ICD. Percentage (%) change in Pred. FVC1, VATS 125%, ICD 92.6%.(Tab8). There is significant increase in Pred. FEV1 at Post treatment in VATS and ICD.Increase in Pred. FEV1 is significantly higher ICD at post treatment. Percentage (%) change in Pred. FEV1, VATS 117.94%, ICD 75.0 %.( Tab9). Average dose/patient is significantly higher in ICD groups than VATS (Tab10). In group – A 80% required only NSAID and 20% required other higher analgesia (ICD Blocks, Thoracic epidural) in group – B only 48.57% where pain free by NSAID only and most of them (51.5%) required other analgesics (Tab11). The rate of empyema, pneumonitis, superficial wound infections, organized hemothorax was significantly higher in group – A and than in group - B. Bronchopleural fistula formation and ventilator dependency is significantly higher in group – B than in group – A(Tab12)..
CONCLUSION: VATS (Video Assisted Thoracoscopic Surgery) is certainly a better option than conventional ICD insertion only, for the management of thoracic injury in terms of better and early pain control; less requirement of analgesics, less duration of hospital stay thereby reducing overall cost of treatment and early restoration of pulmonary functions. VATS is not only of therapeutic benefit but is also reliable for diagnosis of various missed thoracic injuries (eg. Diaphragmatic injury, small lung lacerations).VATS is associated with less complication rate and requires less ventilatory support.