Introduction

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.^[1] 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.^[3] The trend of high speed vehicular transport has worsen the situation in past 3-4 decades.^[3] In the United States alone 12 per million population per day - and 20-25% of deaths due to trauma are attributed to thoracic injury.^[4] 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.^[4]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.^[5]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.^[6] 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.^[7]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. ^[4]

Method

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 1.Clinical improvement in patients after VATS or ICD after 3^rd and 7^th day and with long term follow up in regards to(a)pain(b)dyspnoea .2. Radiological improvement after interventions which was assessed by (a) USG (b) Chest X-ray(c) 3. CECT Improvement in pulmonary functions based on:Pre-procedure and Post – procedure PFT(pulmonary function test) based on two variables (in group – B patients PFT was done after emergency ICD placement), % predicted and FVC% predicted FEV1.4. Comparison of length of hospital stay in both groups . 5. Comparison between total dose of analgesia used and type of analgesia given.

RESULT: The application of VATS (Video assisted thoracic surgery) for diagnosis and treatment of thoracic injury is better than ICD insertion only in terms of outcome.Haemothorax is the most common indication for VATS in thoracic injury. VATS is also effective in diagnosing missed thoracic injuries.

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)..

Figure 1

TABLE 1: Comparison of pain in VATS and ICD at different Time Interval

Figure 2

Table-2: Comparison of Dyspnea in VATS & ICD group

Figure 3

Table-3: Comparison of X-ray (Chest) finding in VATS and ICD

Figure 4

Table-4: Comparison of USG findings among the groups

Figure 5

Table-5: Comparison of hospital stay in two groups

Figure 6

Table 6: Comparison of %Pred. FEV in VATS & ICD groups

Figure 7

Table-7: Comparison of CECT findings in VATS and ICD groups

Figure 8

Table-8: PFT (Pulmonary Function Test) Comparison of %Pred. FVC in VATS & ICD

Figure 9

Table-9: Comparison of %Pred. FEV in VATS & ICD groups

Figure 10

Table-10: Comparison of analgesic consumption in both groups

Figure 11

Table-11 : Type of Analgesic used

Figure 12

Table-12: Complications

DISCUSSION: The most common mechanism was blunt injury following road traffic accident. Blunt trauma accounted for 68.4% and penetrating trauma accounted for 31.6% of total patients. Thoracic injury remains a major source of morbidity and mortality. With the increasing expertise in video assisted thoracic surgery, this modality has become an attractive alternative in the management of patients with thoracic injury. Video assisted thoracic surgery can be used as an effective and safe method for the initial diagnostic evaluation and surgical management of stable patients with thoracic injury. Many questions need to be answered. Is VATS (Video Assisted Thorcoscopic Surgery) safe and effective in management of Thoracic injuries and its sequelae ? Who are the ideal candidates for VATS ? The usual initial management of patients with thoracic injury is placement of ICD (Intercostal Drainage Tube) only and maintaining hemodynamic parameters. This study compared the treatment outcome of thoracic injury patients treated by VATS and those treated by ICD insertion only (a common practice in our institute.) The study evaluated 70 patients of which Group A (VATS) had 35 and Group B (ICD only) also had 35 patients. Patients were assigned to each group by randomization by random card method. Mean age of patients in group - A was 42.5 years and in group - B was 43.13 years. In group – A 28 patients were male and 7 patients were female. In group – B 28 patients were male and 9 patients were female. There was no statistically significant difference in both groups regarding sex and age. In both groups incidence of thoracic injuries was more in male as compared to female. In our study patient were assessed and compared on clinical, radiological, functional bases and various complication rates. Clinically patients were assessed for severity of pain and its improvement. In VATS treated group there was significant improvement in pain on 3^rd post procedure day. There was significant improvement in dyspnea as compared to ICD treated group. The dose of analgesic require was less in VATS. The hospital stay was also significantly less in our study in VATS patients. Same results were obtained in study done by Abolhoda et al., in which the median post-operative hospital stay following successful video assisted thoracic surgery was 3.5 days and concluded that 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 thoracic trauma. Radiological improvement (Based on Chest X-ray, USG thorax, CECT thorax) was also significant in VATS treated patients due to irrigation of hemothorax and blood clots under direct vision. Improvement in pulmonary function is better based on % pred. FVC and % pred. FEV1.In our study the complication rates were less in VATS groups with less rate of empyema; less rate of retained hemothorax and less ventilator dependency. Same results were obtained in study by Krasna et al., 1996. Also in study by Nagasaki et al., 1982; results of complications in VATS were same. The study by Konstantinos Potaris et al. , also concluded that VATS for specific indications in chest trauma is associated with improved outcomes, decreased morbidity and mortality, and shortened hospital stay. In our study one diaphragmatic injury, which was missed by standard radiology, was diagnosed and treated by VATS. But this is not significant to derive any conclusion (1 patient). But a study by Paolo Fabbruccil et al. , conformed both the diagnostic and therapeutic efficacies of VATS in chest trauma with penumothorax and/or hemothorax, yielded excellent results, including an uneventful postoperative course, rapid resolution of the signs and symptoms of the chest problem, and no disabling sequelae (empyema and fibrothorax), as well as a relatively shorter hospital stay and hence lower costs than with conservative treatment . In our study VATS was utilized mainly in hemothorax and in some cases of ongoing thorax parietal bleeding, with better results as compared to ICD group. Similar results were obtained by B. Todd Heniford et al. , Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients. There by , study established VATS as a tool of immense diagnostic and therapeutic importance for patients of thoracic injuries, even for those who belong to underprivileged strata

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.