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Three Part Question

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]?

Clinical Scenario

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.

Search Strategy

(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.

Search Outcome

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.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Abolhoda A et al. 1997 New Jersey, USA	- Between July 1991 and June 1995, 16 patients (0.7% of all admissions) underwent VATS following chest trauma. - 15 penetrating and 1 blunt injuries.	Retrospective Review	- Successful thoracoscopy.	- 12/16 (75%).	Retrospective study, single-centre. Comments: - 4 patients with unsuccessful VATS were converted to standard thoracotomy. - Failure thought to be due to suboptimal single lung ventilation or severe pleural inflammatory reaction.
			- Successful evacuation of retained clotted haemothoraces.	- 9 patients.
			- Median length of hospital stay.	- 3.5 days.
Ben-Nun A et al. 2007 Haifa, Israel	- Medical records of patients with chest trauma over a 10-year period were reviewed. - 77 patients; VATS (37), thoracotomy (40).	Retrospective Review (Level IIb evidence)	- Average operation time.	- 70 minutes, similar in both groups.	Retrospective data.
			- Average length of hospitalisation.	- VATS (6 +/- 2 days), thoracotomy (8 +/- 3 days), p<0.05.
			- “Pain-free” at 2-year follow-up (average 31 months).	- VATS (92%), thoracotomy (50%), p<0.05.
Goodman M et al 2013 Cincinatti, Ohio, USA	- Between 1999 and 2010, trauma registry was searched for chest trauma patients who underwent VATS within 24h of admission. - 23 patients included. - 3 blunt and 20 penetrating injuries.	Retrospective Review (Level IIb evidence)	- Mean total operating time.	- 116 +/- 16 minutes.
			- Mean total length of hospitalisation.	- 5.6 +/- 0.9 days.
			- Mean post-operative chest tube duration.	- 2.9 days.
Lang-Lazdunski L et al. 1997 Clamart, Nice, France	- Between July 1990 and April 1996, 42 patients with chest trauma who underwent VATS were analysed. - 21 blunt and 21 penetrating injuries.	Retrospective review (Level IIb evidence)	- Conversion to thoracotomy.	- 10 patients (24%).	Retrospective review
			- Peri-operative death.	- 1 patient.
			- Mean length of hospital stay.	- 17 days. Blunt trauma (21 days), penetrating trauma (13 days).
Liw DW et al. 1997 Taipei, Taiwan	- From July 1994 to December 1995, 56 chest trauma patients received thoracic surgery. - 50 patients underwent VATS. - 31 blunt and 19 penetrating injuries.	Retrospective Review	- Morbidity or mortality.	- 0%.	Retrospective data (Level IIb evidence)
			- Average length of post-operative stay.	- 13 days.
Manlulu AV et al. 2004 Hong Kong, China	- A 6-year single institution review of patients undergoing VATS for blunt and penetrating chest trauma. - VATS performed in 19 patients. - 8 blunt and 11 penetrating injuries.	Retrospective review	- Conversion to thoracotomy.	- 0%.	Retrospective data
			- Morbidity.	- 0%.
			- Average length of post-operative stay.	- 5.86 days.
Meyer DM et al. 1997 Texas, USA	- Prospective randomisation of patients with retained traumatic haemothorax. - Group 1 – second tube thoracostomy (n=24). - Group 2 – VATS (n=15).	Prospective, randomised study.	- Total hospital stay.	- Group 1 – 8.13 +/- 4.62 days, Group 2 – 5.40 +/- 2.16 days; p<0.02.	- Small population size. - Group 1 patients were younger and had fewer associated injuries
			- Hospital costs.	- Group 1 – $13,273 +/- $8158, Group 2 – $7689 +/- $3278; p<0.02).
			- Conversion to thoracotomy.	- Group 2 – 0 patients. 10 group 1 patients failed repeat tube placement and were equally randomised to VATS or thoracotomy (n=5). No significant difference in clinical outcome found between these subgroups.
Milanchi S et al 2009 California, USA	- Trauma patients at a single centre undergoing VATS from 2000 to 2007. - 23 patients identified.	Retrospective review.	- VATS failure.	- 2/25 (8%).	Retrospective data.
			- Mortality.	- 0/23.
			- Average length of hospital stay.	- 20 days (range 3-58).
Paci M et al. 2006 Reggio Emilia, Italy.	- 1270 thoracic trauma patients admitted between 1994 and 2004. - 16 penetrating injuries. - 13/16 explored by VATS.	Retrospective review	- Intra- or post-operative mortality.	- 0/13.	- Single centre, non-randomised, non-prospective trial.
			- Average length of hospital stay.	- 5 days.
Pons F et al. 2001 Clamart, France	- 13 thoracic trauma patients with penetrating injury admitted over a 4-year period underwent VATS. - 85% of patients had VATS within 8h of trauma.	Retrospective Review	- Conversion to thoracotomy.	- 4/13.	Retrospective Data
			- Mean operative time	- 37 +/- 23 minutes
			- In-hospital mortality.	- 0/13.
			- Average length of hospital stay.	- 10 +/- 4 days.
Potaris K et al. 2005 Kiffisia, Greece	- Between Jan 1999 and Sept 2004, 25,213 patients presented with chest trauma, with 2304 being admitted. - 23 patients (1%) underwent VATS.	Retrospective review.	- Conversion to thoracotomy.	- 4/23 (17%).	Retrospective data.
			- Mortality.	- 0/23 (0%).
			- Average length of hospital stay.	- 7.6 days.
Smith JW et al. 2011 Louisville, Kentucky, USA.	- Between Jan 2007 and Dec 2009, 83 patients with blunt thoracic injuries underwent VATS.	Retrospective Review.	- Conversion to thoracotomy.	- VATS performed less than or equal to 5 days post-injury – 8%, versus 29.4%; p<0.05.	- Outcomes reported in this study were similar in other studies reporting on penetrating trauma. - Retrospective data.
			- Average length of hospital stay.	- VATS performed less than or equal to 5 days post-injury – 11 +/- 6 days versus 16 +/- 8 days; p<0.05.
Villavicencio RT et al. 1999 Pittsburgh, USA	- Systematic analysis of 28 non-overlapping studies with a combined patient population of more than 500.	Systematic retrospective review.	- Prevention of thoracotomy or laparotomy.	- 62% (323/514).	- No statistical analysis on data. - Collaborative retrospective review of accrued data.
			- Accuracy rate in diagnosing diaphragmatic injuries.	- 98% (188/191).
			- Efficacy in evacuating retained haemothoraces.	- 90% (89/99).

Comment(s)

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.

Clinical Bottom Line

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.

References

1. Abolhoda A, Livingston DH, Donahoo JS, Allen K. Diagnostic and therapeutic video assisted thoracic surgery (VATS) following chest trauma Eur J Cardiothorac Surg. 1997;12:356–60.
2. Ben-Nun A, Orlovsky M, Anson Best L. Video-Assisted Thoracoscopic Surgery in the Treatment of Chest Trauma: Long-Term Benefit. Ann Thorac Surg 2007;83:383-7.
3. Goodman M, Lewis J, Guitron J, Reed M, Pritts T, Starnes S. Video-assisted thoracoscopic surgery for acute thoracic trauma. J Emerg Trauma Shock. 2013;Apr-Jun;6(2):106-109.
4. Lang-Lazdunski L, Mouroux J, Pons F, Grosdidier G, Martinod E, Elkaïm D. Role of videothoracoscopy in chest trauma. Ann Thorac Surg. 1997;63:327–33.
5. Liu DW, Liu HP, Lin PJ, Chang CH. Video-assisted thoracic surgery in treatment of chest trauma. J Trauma 1997;Apr;42(4):670-4.
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. Eur J Cardiothorac Surg. 2004;25:1048–53.
7. Meyer DM, Jessen ME, Wait MA, Estrera AS. Early evacuation of traumatic retained hemothoraces using thoracoscopy: A prospective, randomized trial Ann Thorac Surg 1997;64:1396–400.
8. Milanchi S, Makey I, McKenna R, Margulies DR. Video-assisted thoracoscopic surgery in the management of penetrating and blunt thoracic trauma. J Min Access Surg. 2009;5(3):63-6.
9. Paci M, Ferrari G, Annessi V, de Franco S, Guasti G, Sgarbi G. The role of diagnostic VATS in penetrating thoracic injuries. World J Emerg Surg 2006;1:30.
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 Eur J Cardiothorac Surg. 2002;22:7-12.
11. Potaris K, Mihos P, Gakidis I. Role of video-assisted thoracic surgery in the evaluation and management of thoracic injuries. Interact Cardiovasc Thorac Surg. 2005;4:292-294.
12. Smith JW, Franklin GA, Harbrecht BG, Richardson JD. Early VATS for blunt chest trauma: A management technique underutilized by acute care surgeons. J Trauma 2011;71:102–7.
13. Villavicencio RT, Aucar JA, Wall, Jr. MJ. Analysis of thoracoscopy in trauma. Surg Endosc. 1999;13:3-9.
14. Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact Cardiovasc Thorac Surg. 2003;2:405-409.
15. Ahmed N, Jones D. Video-assisted thoracic surgery: state of the art in trauma care. Injury, Injury, Int J Care Injured. 2004;35:479-489.
16. Cetindag IB, Neideen T, Hazelrigg SR. Video-assisted thoracic surgical applications in thoracic trauma. Thorac Surg Clin. 2007;17:73–9.