|Year : 2020 | Volume
| Issue : 4 | Page : 180-184
Thoracotomy for chest trauma: Indication, operative finding, and outcome
Kelechi E Okonta1, Christain E Amadi1, Peter D Okoh2, Christopher N Ekwunife3
1 Department of Surgery, Cardiothoracic Surgery Unit, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria
2 Department of Surgery, General Surgery Unit, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria
3 Department of Surgery, Federal Medical Centre, Owerri, Imo State, Nigeria
|Date of Submission||27-Sep-2021|
|Date of Acceptance||07-Oct-2021|
|Date of Web Publication||30-Dec-2021|
Kelechi E Okonta
Department of Surgery, Cardiothoracic Surgery Unit, University of Port Harcourt, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Background: To evaluate indication and result of open posterolateral thoracotomy done in the theatre for chest trauma (CT).
Methods: During a 5-year period, our team performed thoracotomies in a total of 24 patients out of the 307 patients who had CT. The demographic data, type, mechanism, clinical diagnoses, operative finding, Injury Severity Score, case-fatality rate, and complication of the CT were computed with the descriptive statistics were presented in percentage and fraction. All the surgeries were performed by the same team.
Results: Of the 307 patients who sustained CT, 24 patients (7.8%) had open posterolateral thoracotomy done in the theater. The mean age was 31.2 (standard deviation ± 13.10) years with a male-to-female ratio of 7:1. The cause of CT was gunshot injury 13 (54.2%) patients, motor vehicular accident in 5 (20.8%) patients, stab injury in 5 (20.8%) patients, and fall 1 (4.2%) patient. The diagnosis was made following the assessment of the quantity and quality of the output of inserted chest tube, auscultated bowel sounds in the chest, chest radiograph, and chest ultrasound. The operative finding was diaphragmatic injury in 13 patients (54.2%), lung laceration in 5 patients (20.8%), negative in two patients (8.3%), bullet in the pleural space in two patients (8.3%), and trachea-bronchial injury and bleeding internal mammary artery (4.2%) in a patient each. The case-fatality rate was 17.4%.
Conclusion: Massive hemothorax remains the most common reason for the thoracotomy with diaphragmatic injury being the most common intraoperative finding. Diaphragmatic rupture should be ruled out before the insertion of chest tube for traumatic hemothorax or pneumothorax.
Keywords: Case-fatality, chest trauma, massive hemothorax, thoracotomy
|How to cite this article:|
Okonta KE, Amadi CE, Okoh PD, Ekwunife CN. Thoracotomy for chest trauma: Indication, operative finding, and outcome. Saudi Surg J 2020;8:180-4
| Introduction|| |
Chest trauma (CT) is the leading cause of mortality in all sexes and all age groups.,,, CT, a physical injury affecting the chest wall, pleural space, heart, lungs, vessels, diaphragm, esophagus, etc., accounts for 25% of mortality in the patients with trauma and with the chest being affected in 50% of those with multiple trauma.,, In the majority of cases, such patients would need an immediate evaluation to determine the need for surgical intervention such as chest tube insertion or open thoracotomy., For patients with multiple traumas, CT has a quantifiable impact with regard to the rate of organ failure, length of ICU stays, and mortality rate.,,,
The management of CT can be quite challenging because of the possibility of a high rate of emergency surgeries,,,, that may be required especially the one done in an emergency department thoracotomy. Although the majority of patients with significant CT are treated with chest tube insertion, some may require emergency thoracotomy to correct some life-threatening conditions.,,,,, Again, the need for emergent or urgent or elective thoracotomy may not be immediately evident on admission but may be identified subsequently when the immediate life-threatening conditions have been tackled.,, Thus, the surgery for such patient may be emergent or urgent or elective in timing.
Studies across the globe such as Nigeria, Syria, the USA, Kuwait, Egypt, and Belgium showed that the rate for open thoracotomy for CT patients could range from 2.6% to 12.1%.,,,,, A review in Nigeria, in which only emergent cases were considered, the reported rate of thoracotomy following CT was 5%. Interestingly, most emergency thoracotomies may not actually require the presence of thoracic surgeons as patient with such injury requiring thoracotomy may present at the time the resident doctors are the ones on call or likely to be around. And importantly, this may be done at the scene of an injury or in the emergency department or done in the operating room to evacuate pericardial tamponade, allow for the internal cardiac massage, control hemorrhage from the heart, vessels and lung, and cross-clamp the descending thoracic aorta to improve blood flow to the coronary and cerebral vessels and may limit sub-diaphragmatic hemorrhage.,,,
From the reviewed literatures, the indications for open thoracotomy whether emergency or urgency or elective are for massive air leak from significant trachea-bronchial injury, massive hemothorax, diaphragmatic injury, clotted hemothorax, and empyema thoracic with cicatrising atelectasis.,,
Thus, the aim of this study was to determine the rate, indication, and case fatality for open posterolateral thoracotomy done in the theatre for CT.
| Methods|| |
This was a prospective, observational study of all the consecutive patients with CT presenting in two tertiary hospitals the University of Port Harcourt and Federal Medical Center Owerri all in the southern part of Nigeria for a 5-year period. The two hospitals are in Rivers state and Imo state, respectively. These two states have a combined population of over 9 million people. Included are all patients who had posterolateral thoracotomy in the theater whether as emergency or elective basis, and excluded were patients who died before or while having thoracotomy, or who were discharged against medical advice. The demographic data of the patients, the type of chest injury (Blunt versus penetrating), the mechanism of the chest injury, the clinical diagnoses of the patients, the intra-operative findings, the Injury Severity Score (ISS), the outcome into dead or alive, the complications. The diagnoses were made from proper clinical evaluation of the patient, chest ultrasound, Chest radiograph and the quantity and quality of the inserted chest tube drainage. The descriptive statistics were presented in percentage and fraction. The participant gave their consent to take part in this study and confidentiality was ensure for each patient.
| Results|| |
Of the 307 patients who were managed for CT during the 5-year period, 24 (7.8%) had open posterolateral thoracotomy done in the theatre. The mean age was 31.2 (standard deviation ± 13.10) years with the male-to-female ratio was 7:1. On the type of CT; it was penetrating chest injury in 18 (75.0%) patients and blunt chest injury in 6 (25.0%) patients. On the mechanism of injury: About 13 (54.2%) patients had Gunshot injury, 5 (20.8%) patients had motor vehicular crash patients, stab injury in 5 (20.8%) patients, fall in 1 (4.2%) patient. The mode of diagnoses was: Through the insertion of chest tube with evidence of massive haemothorax in 13 (54.2%) patients, the inserted chest tube draining intestinal contents in 2 (8.3%) patients, evidence of bowel sound on chest auscultation and bowel outline on chest radiograph in 5 (20.8%) patients, 1 (4.2%) patient each for massive air leak, presence of a bullet in the chest, diaphragmatic rupture and cicatrizing atelectasis with empyema thoracic complicating penetrating chest injury [Table 1]. The modality for achieving diagnosis was by clinical evaluation in 3 patients (12.5%), chest radiograph in 4 patients (16.7%), the output of chest tube in 16 patients (66.7%) and the use of both clinical evaluation and chest radiograph in 1 patient (4.2%). The operative findings were diaphragmatic injury in 13 patients (54.2%), lung laceration in 5 patients (20.8%), negative in 2 patients (8.3%), bullet in the pleural space in 2 patients (8.3%), trachea-bronchial injury in 1 patient (4.2%), and bleeding internal mammary artery in 1 patient (4.2%) [Table 2]. The main complication of postoperation was empyema thoracis in three patients (12.5%) and the case fatality rate was in four patients (16.7%).
| Discussion|| |
The rate of open thoracotomy in this review was <10%; and this was similar to the finding from other studies around the world.,,,, The observed difference in the rate across countries was due to the type of chest injury vis-à -vis blunt or penetrating CT. Our observation was that those patients who sustained penetrating chest injuries were more likely to have thoracotomy than those with blunt chest injuries. Again, the indication for open thoracotomy tends to be common with penetrating CT than blunt chest injuries as noted in our case series. The penetrating injuries tend to be more in patients with gunshot injuries than those who sustained penetrating injuries from other means. Similar studies in the country noted that Gunshot injuries were a major cause of morbidity in the country.,
The commonest indication for thoracotomy from this review was massive haemothorax; which was detected by the amount and nature of drainage from the inserted chest tube as initial treatment of the pleural collection after CT. Massive haemothorax as an indication for open thoracotomy was the main reason for immediate surgery in many studies that were reviewed.,,,, In general, massive hemothorax can be divided into two categories, based on etiology: Penetrating and blunt CT. The diagnosis of massive hemothorax is made by observing the drainage from the chest tube of about 1.5 L or more of fresh blood or the drainage of 200 ml of blood every 1 h for 3 consecutive h for adults or the drainage of 3 ml/kg of body weight for 3 consecutive h.,, The hemothorax following CT may result from bleeding from a wide range of structures such as diaphragmatic laceration, vessels such as the internal mammary artery, intercostals artery, and worse from the major vessels.
Relying on the chest tube output for a patient with CT in other to make a decision as to the need for thoracotomy or not has its merits and demerit. In a multicenter study done in the US, it was observed that delayed surgery as a result of prolonged observation of chest tube drainage increased the risk for death to 3.2 times if chest tube drainage exceeded 1500 mL before open thoracotomy than with chest tube drainage of 500 mL or less. In another study, it was stated that high chest tube output as a traditional indicator for thoracotomy may not apply to patients with blunt CT; and relying on an hourly output or waiting for evidence of haemodynamic instability may not be as a criterion to determine carrying out emergency thoracotomy in a patient with critical CT. Thus, different centres, saddled with their local challenges, have devised different methods of reducing morbidity and mortality in patients who have massive hemothorax. For instance, in our setting, we did not have an emergency operating suite set out for thoracic surgical cases alone, and we had to use other suites, thus we had a slightly increased propensity to going into the theater with drainage of over 1.5 L of blood at the insertion of the chest tube and/or the subsequent draining of 200 ml of fresh blood. Most times, in our center, we do not wait for 2 consecutive h to observe the drainage of 300 ml every hour before carrying out thoracotomy. However, the decision for thoracotomy is taken after the 1st h of the drainage of 300 ml in an adult patient.
Managing lung laceration from penetrating chest injury, especially missile injury can be a challenging task. This is because bleeding may be so torrential, and in some cases, emergency lobectomy or pneumonectomy may have to be done. However, taking such a decision may not be an easy one as the surgeon may keep on searching for the bleeding point, and the frequent intent of adopting lung-sparing techniques instead of lobectomy or pneumonectomy. In one of the patients, while we were searching for the bleeding point and making attempts at conserving the lung, the patient developed coagulopathy on the operating table that was unresponsive to corrective measures and died.
The presence of a foreign body like a bullet with accompanied cicatrizing atelectasis and empyema thoracis in one patient with complaints of chronic back pain was the indication for open thoracotomy in other to relieve symptoms and ensure the removal of, possible, the source of the chest infection.
However, with the patient proper clinical evaluation and the use of radiological and ultrasound armamentariums, bowel sounds and bowel outline were noticed in the chest indicating likely diaphragmatic rupture. Some of the patients were diagnosed by clinical evaluation with careful auscultation of the chest for bowel sounds and subsequently complemented with chest ultrasound or chest radiography. The use of imaging facilities like ultrasound and contrast computerized tomography is quite good in making diagnoses of diaphragmatic injury, especially in a chronic and stable patient.
Making the diagnosis of massive air leak by the use of bronchoscopy, especially for an unstable patient, can be a challenge and imposes a diagnostic conundrum. But in our setting, we were able to navigate that by passing a chest tube, and then observing for evidence of continuous excessive bubble of the chest tube underwater chamber; and accompany severe respiratory distress became quite helpful in deciding the need for thoracotomy.
The mortality rate from this study was similar to the mortality rate reports about three decades ago. In a multicenter study, it was observed that there was no single independent preoperative factor that could linearly predict mortality for patients undergoing thoracotomy for critical CT, but another study identified the duration of the emergency thoracotomy and the heart rate at the end of procedure were the predictors of survival. Equally noted as a predictor of survival from one of the largest case series reviewed were patients presenting with pulseless after penetrating thoracic injury. However, what has been consistent is that the mortality rate depends on ISS, the urgency of intervention, and identification of the problem.
| Conclusion|| |
Thoracotomy as a modality for the management of patients with CT is still quite uncommon. Massive hemothorax still remains the most common reason for thoracotomy with diaphragmatic injury the most common intraoperative finding. There is a need to rule out diaphragmatic rupture before the insertion of a chest tube for traumatic hemothorax or pneumothorax. Even when a chest tube is inserted for a CT patient for the evacuation of hemothorax, there is the need to carefully monitor the quality and quantity of the output in other to determine the need for open thoracotomy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ekeke ON, Okonta KE, Igwe PO. Surgical inpatient mortality in a Nigerian Tertiary Hospital. Niger J Clin Pract 2016;19:308-12.
] [Full text]
Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma – A review. Injury 2006;37:1-19.
Karmy-Jones R, Jurkovich GJ, Nathens AB, Shatz DV, Brundage S, Wall MJ Jr., et al.
Timing of urgent thoracotomy for hemorrhage after trauma: A multicenter study. Arch Surg 2001;136:513-8.
Mattox KL, Wall MJ, Tsai P. Trauma thoracotomy: Principles and techniques. In: Mattox KL, Moore EE, Feliciano DV, editors. Trauma. 7th
ed. New York: McGraw-Hill; 2013. p. 461-7.
Ludwig C, Koryllos A. Management of chest trauma. J Thorac Dis 2017;9:S172-7.
LoCicero J 3rd
, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am 1989;69:15-9.
Bayer J, Lefering R, Reinhardt S, Kühle J, Zwingmann J, Südkamp NP, et al.
Thoracic trauma severity contributes to differences in intensive care therapy and mortality of severely injured patients: Analysis based on the TraumaRegister DGU®
. World J Emerg Surg 2017;12:43.
Bayer J, Lefering R, Reinhardt S, Kühle J, Südkamp NP, Hammer T, et al.
Severity-dependent differences in early management of thoracic trauma in severely injured patients – Analysis based on the TraumaRegister DGU®
. Scand J Trauma Resusc Emerg Med 2017;25:10.
Okonta KE, Ocheli EO. Blunt chest injury: Epidemiological profile and determinant of mortality. Int Surg J 2018;5:1622-7.
Al-Koudmani I, Darwish B, Al-Kateb K, Taifour Y. Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: A retrospective review of 888 cases. J Cardiothorac Surg 2012;7:35.
Demirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: A 10-year experience. Interact Cardiovasc Thorac Surg 2009;9:450-3.
Adebonojo SA. Management of chest trauma: A review. West Afr J Med 1993;12:122-32.
Kulshrestha P, Munshi I, Wait R. Profile of chest trauma in a level I trauma center. J Trauma 2004;57:576-81.
Hanafi M, Al-Sarraf N, Sharaf H, Abdelaziz A. Pattern and presentation of blunt chest trauma among different age groups. Asian Cardiovasc Thorac Ann 2011;19:48-51.
Ismail MF, al-Refaie RI. Chest trauma in children, single center experience. Arch Bronconeumol 2012;48:362-6.
Segers P, Van Schil P, Jorens P, Van Den Brande F. Thoracic trauma: An analysis of 187 patients. Acta Chir Belg 2001;101:277-82.
Sersar SI, Alanwar MA. Emergency thoracotomies: Two center study. J Emerg Trauma Shock 2013;6:11-5. [Full text]
Mansour MA, Moore EE, Moore FA, Read RR. Exigent postinjury thoracotomy analysis of blunt versus penetrating trauma. Surg Gynecol Obstet 1992;175:97-101.
Chang SW, Ryu KM, Ryu JW. Delayed massive hemothorax requiring surgery after blunt thoracic trauma over a 5-year period: Complicating rib fracture with sharp edge associated with diaphragm injury. Clin Exp Emerg Med 2018;5:60-5.
Abbas AD, Bakari AA, Abba AM. Epidemiology of armed robbery-related gunshot injuries in Maiduguri, Nigeria. Niger J Clin Pract 2012;15:19-22. [Full text]
Mohammed AZ, Edino ST, Ochicha O, Umar AB. Original article epidemiology of gunshot injuries in Kano, Nigeria. Niger J Surg Res 2005;7:296-9.
Igai H, Kamiyoshihara M, Yoshikawa R, Ohsawa F, Yazawa T. Delayed massive hemothorax due to a diaphragmatic laceration caused by lower rib fractures. Gen Thorac Cardiovasc Surg 2019;67:811-3.
Oncel M, Sunam GS, Yildiran H. Recognition and management of traumatic massive hemothorax: Evaluation of 67 cases. Clin Surg 2017;2:1555.
Mizushima Y, Nakao S, Watanabe H, Matsuoka T. Thoracotomy for blunt chest trauma: Is chest tube output a useful criterion? Acute Med Surg 2016;3:81-5.
Onat S, Ulku R, Avci A, Ates G, Ozcelik C. Urgent thoracotomy for penetrating chest trauma: Analysis of 158 patients of a single center. Injury 2010;41:876-80.
Dienstknecht T, Horst K, Sellei RM, Berner A, Nerlich M, Hardcastle TC. Indications for bullet removal: Overview of the literature, and clinical practice guidelines for European trauma surgeons. Eur J Trauma Emerg Surg 2012;38:89-93.
Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma 1993;35:255-60.
Kish G, Kozloff L, Joseph WL, Adkins PC. Indications for early thoracotomy in the management of chest trauma. Ann Thorac Surg 1976;22:23-8.
Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: Review of published data from the past 25 years. J Am Coll Surg 2000;190:288-98.
Refaely Y, Koyfman L, Friger M, Ruderman L, Abu Saleh M, Klein M, et al.
Predictors of survival after emergency department thoracotomy in trauma patients with predominant thoracic injuries in Southern Israel: A retrospective survey. Open Access Emerg Med 2019;11:95-101.
Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, et al.
An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015;79:159-73.
[Table 1], [Table 2]