Evidence supporting Video Assisted Thoracoscopic Surgery as the standard of care in the sub-acute management of the haemodynamically stable chest trauma patient: a review

March 10, 2014

March 11, 2014

Akshay J. Patel (First Author), Ian Hunt (Second Author)., FY2 Doctor - Surgery (St. George's Hospital, London)

Akshay J Patel, St. George's Hospital, London

Does [Video-Assisted Thoracoscopic Surgery] reduce the incidence of [morbidity, mortality, pain and length of post-operative hospital stay] experienced by adult patients post [blunt or penetrating thoracic trauma]?

The trauma team including the cardiothoracic surgical department discusses at a grand round meeting the introduction of a new “adult thoracic trauma” management protocol after patients with thoracic trauma have been stabilised in the emergency department. This protocol involves the use of Video-Assisted Thoracoscopic Surgery (VATS). You are not sure whether VATS is a safe and effective technique for managing thoracic trauma so you decide to look up the evidence yourself.

(Trauma OR “wound”[MeSH] OR “injury”[MeSH]) AND (“thorax”[MeSH] OR thoracic OR chest) AND (acute OR blunt OR penetrating) AND (“video-assisted” thoracoscopic surgery[MeSH] OR “thoracoscopy”[MeSH] OR videothoracoscopy OR VATS)

As above.

A total of 221 papers were identified. Relevant papers were identified and their references screened. Of these, 13 papers were deemed to provide the best evidence to answer our clinical question.

Twenty-five percent of mortality in trauma patients is related to injuries sustained to the thoracic cavity, a proportion of these deaths are attributable to immediate exsanguination or cardiac tamponade [Ahmed N]. Approximately 15% of patients who sustain such trauma need to undergo immediate thoracotomy for resuscitation, the remaining 85% of patients can be initially managed with tube thoracostomy, analgesia, pulmonary wash-out and observation [Cetindag]. Improvements in endoscopic technology have expanded the indications for video-thoracoscopy both in the diagnosis and management of the complications of thoracic trauma [Manlulu AV], despite this, its definitive role is yet to be delineated [Liu DW].
Retrospective analysis of 16 patients undergoing VATS for thoracic trauma showed a success rate of 75% (12/16). Nine patients successfully had their clotted haemothoraces evacuated. Median length of hospital stay was 3.5 days [Abolhoda A].
Ben-Nun et al [Ben-Nun A] analysed 77 thoracic trauma patients; 37 underwent VATS and 40 underwent thoracotomy. Average length of hospital stay was significantly shorter in the VATS group (6 +/- 2 days versus 8 +/- 3 days; p<0.05). In the VATS group, 92% of patients were “pain-free” at 2-year follow-up compared with 50% in the thoracotomy group; p<0.05.
A level I trauma centre’s registry [Goodman M] was searched for all thoracic trauma patients undergoing VATS within 24h; n=23. No conversion to thoracotomy was required and there was no need for re-operation. Mean post-operative chest tube duration was 2.9 days with an average length of stay of 5.6 +/- 0.9 days.
VATS was performed on 42 thoracic trauma patients at a single centre, the conversion rate to open thoracotomy was 24% with one peri-operative death. The average length of post-operative stay was 17 days; 13 days for penetrating and 21 days for blunt trauma [Lang-Lazdunski L].
Liu et al prospectively analysed 56 thoracic trauma patients; 50 underwent VATS. There was no recorded morbidity or mortality, the average length of stay was 13 days and recovery at 1-year follow-up was uneventful [Liu DW].
A single institution retrospectively reviewed 19 thoracic trauma patients who underwent VATS over a 6-year period. There was no recorded morbidity and the conversion to thoracotomy rate was 0%. Average length of post-operative stay was 5.86 days [Manlulu AV].
A prospective trial randomised patients with retained traumatic haemothorax to a VATS group (n=15) and a second tube thoracostomy group (n=24). No patients in the VATS group required conversion to thoracotomy, whereas 10 patients in the thoracostomy group failed the second tube insertion. Total hospital stay was significantly lower in the VATS group; 5.4 +/- 2.16 days versus 8.13 +/- 4.62 days, p<0.02 [Meyer DM].
Twenty-five VATS procedures took place at a single centre for thoracic trauma over a 7-year period. There was an 8% failure rate but no mortality. Average length of hospital stay was 20 days [Milanchi S].
Sixteen penetrating thoracic trauma cases at a single-centre underwent 13 VATS procedures. Retrospective analysis revealed no mortality, and a 5-day average length of hospital stay [Paci M].
VATS was performed on 13 penetrating thoracic trauma patients over a 4-year period. Conversion to thoracotomy was necessary in 4/13 patients. There was no in-hospital mortality. Average length of hospital stay was 10 +/- 4 days [Pons F].
Retrospective analysis of 23 thoracic trauma patients undergoing VATS revealed a 17% conversion to thoracotomy rate, a 0% mortality rate and an average length of hospital stay of 7.6 days [Potaris K].
Smith et al [Smith JW] report on 83 patients with blunt thoracic injuries, who underwent VATS. If performed within 5 days post-injury, the conversion to thoracotomy rate was 8% versus 29.4% in those performed beyond the 5-day mark. Similarly, average length of stay in those who underwent VATS within 5 days was 11 +/- 6 days versus 16 +/- 8 days; p<0.05.
Villavicencio et al [Villavicencio RT] systematically reviewed 28 studies looking at the role of VATS in thoracic trauma. It was deemed that VATS prevents thoracotomy in 62% of patients (323/514) and has a 98% accuracy rate in diagnosing diaphragmatic injury. Furthermore, there is a 90% efficacy in evacuating retained haemothoraces.

A review of the evidence shows that VATS affords diagnostic and therapeutic benefits when used in the sub-acute management of the haemodynamically stable chest trauma patient [Ahmed N]. The use of VATS can avoid unnecessary thoracotomy [Villavicencio RT] and superior long-term outcomes have been noted with VATS compared to thoracotomy in terms of morbidity, post-operative pain and length of hospitalisation [Ben-Nun A].
Furthermore, early thoracoscopic intervention can further reduce length of stay and need for thoracotomy [Smith JW]. The main contraindication to VATS in the setting of trauma would be haemodynamic instability where urgent sternotomy or laparotomy would be warranted to ascertain intra-abdominal injury in the multiply injured patient [Manlulu AV].
The evidence reviewed is largely retrospective data and larger, prospective, randomised data sets are warranted to ascertain whether VATS should be the initial approach in all stable thoracic traumas.

1. Abolhoda A, Livingston DH, Donahoo JS, Allen K. . Diagnostic and therapeutic video assisted thoracic surgery (VATS) following chest trauma
2. Ben-Nun A, Orlovsky M, Anson Best L.. Video-Assisted Thoracoscopic Surgery in the Treatment of Chest Trauma: Long-Term Benefit.
3. Goodman M, Lewis J, Guitron J, Reed M, Pritts T, Starnes S. . Video-assisted thoracoscopic surgery for acute thoracic trauma.
4. Lang-Lazdunski L, Mouroux J, Pons F, Grosdidier G, Martinod E, Elkaïm D. . Role of videothoracoscopy in chest trauma.
5. Liu DW, Liu HP, Lin PJ, Chang CH. . Video-assisted thoracic surgery in treatment of chest trauma.
6. Manlulu AV, Lee TW, Thung KH, Wong R, Yim AP. . Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries.
7. Meyer DM, Jessen ME, Wait MA, Estrera AS.. Early evacuation of traumatic retained hemothoraces using thoracoscopy: A prospective, randomized trial
8. Milanchi S, Makey I, McKenna R, Margulies DR.. Video-assisted thoracoscopic surgery in the management of penetrating and blunt thoracic trauma.
9. Paci M, Ferrari G, Annessi V, de Franco S, Guasti G, Sgarbi G. . The role of diagnostic VATS in penetrating thoracic injuries.
10. Pons F, Lang-Lazdunski L, de Kerangal X, Chapuis O, Bonnet PM, Jancovici R. The role of videothoracoscopy in management of precordial thoracic penetrating injuries
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