RESULTS
During this study period, 1958 patients with blunt chest injuries were admitted to our hospital. In total, 1352 patients complicated with haemothorax or pneumothorax were treated with tube thoracostomies. About 15% of patients (203 patients) had retained pleural collections so that surgical interventions had to be arranged. Eighty-eight patients having type III lung lacerations diagnosed by chest CT were enrolled, including 71 males and 17 females. There was a wide variation in the age distribution, ranging from 18 to 87 years, with a mean age of 53.57 (±16.10) years. The cohort included 54 patients with motorcycle accidents, 11 with walking or bicycle accidents, 12 with falls and 11 with car accidents. Of these, only 7 patients had single chest trauma, while the remainder had two or more sites of injury, including 32 head injuries, 28 abdominal injuries and 51 fractured limbs. The mean AIS of the chest was 3.25. Eighty-five patients were admitted to the ICU for close observation.
Forty-three patients who underwent thoracoscopic evacuation methods were stratified into Group 1. The remaining 45 patients who underwent evacuation plus resection and repair by thoracoscopic methods were stratified into Group 2. The characteristics and demographics are listed in Table 2. The distributions of age and gender of the two groups were comparable, along with a comparable proportion of flail chest, number of rib fractures and mean AIS of chest. However, Group 2 had slightly higher grades in injury severity scores (ISSs), but there was no statistical and clinical significance (16.40 ± 4.46 vs 18.07 ± 5.84, P = 0.134).
Table 2: Comparison of patient characteristics and demographics between two groups with different surgical interventions
Evacuation (43)Group 1 Evacuation with resection-repair (45)Group 2 P-value
Age 54.95 ± 14.87 52.24 ± 17.26 0.432
Gender (male) 34 (79.1%) 37 (82.2%) 0.708
Number of fractured ribs 5.93 ± 2.93 5.36 ± 2.52 0.327
Flail chest 18 (41.9%) 18 (40.0%) 0.859
Patients with lung contusion involving more than two lobes 40 (93.0%) 43 (95.6%) 0.608
Pulmonary contusion score 7.84 ± 2.79 8.47 ± 1.63 0.203
Acute respiratory failure in 4 h after trauma 19 (44.2%) 15 (33.3%) 0.296
Time from trauma to VATS 7.30 ± 6.54 6.31 ± 2.59 0.356
ISS 16.40 ± 4.46 18.07 ± 5.84 0.134
AIS chest 3.19 ± 0.39 3.31 ± 0.47 0.178
AIS: abbreviated injury score; ISS: injury severity score.
The pulmonary contusion scores were calculated and recorded according to the chest radiological images. Nearly all patients had lung contusions involving more than two lobes of the lung (93.0 vs 95.6%, P = 0.608) and pulmonary contusion scores were nearly equal between the two groups (7.84 ± 2.79 vs 8.47 ± 1.63, P = 0.203). Because most patients had multiple traumas, the overall mean time from trauma to the operation was 6.79 ± 4.92 days. The timing of operation was not statistically significant between the two groups (7.30 ± 6.54 days vs 6.31 ± 2.59 days, P = 0.356). Thirty-four patients received endotracheal tube intubation within 4 h after trauma and the percentage of immediate acute respiratory failures was nearly the same in both groups (44.2 vs 33.3%, P = 0.296).
The clinical outcomes are listed in Table 3. Post-traumatic infections occurred in 44 patients. Group 1 patients had more post-traumatic infections confirmed by higher positive microbial cultured rates in sputum and pleural effusions (65.1 vs 35.6%, P = 0.006; 46.5 vs 17.8%, P = 0.004). The mean ventilator utilization time was 10.32 (±12.26) days. In Group 1, the mean ventilator usage times were longer than Group 2 (13.61 ± 14.88 vs 7.18 ± 8.05 days, P = 0.015). The overall mean duration of chest tube usage was 13.88 (±9.70) days, with a shorter duration in Group 2 when compared with Group 1 (16.65 ± 12.56 vs 11.24 ± 4.55 days, P = 0.010). The overall mean length of stay (LOS) in the ICU was 12.26 (±12.97) days, with Group 2 having a shorter stay in the ICU when compared with Group 1 (16.60 ± 16.90 vs 8.11 ± 4.91 days, P = 0.003). The total in-hospital LOS in Group 2 was much shorter than for Group 1 (34.07 ± 24.23 days compared with 19.38 ± 11.39 days, P = 0.001). The blood loss during VATS was difficult to estimate due to surgical haemorrhage being mixed with retained effusions. Because no patient was converted to thoracotomy in this study, we thought the blood loss in the VATS procedure was small. Group 2 had slightly higher evacuated volume than the other, but there was no statistical significance (448.37 ± 84.23 vs 470.22 ± 63.73, P = 0.175).
Table 3: Comparison of clinical outcomes between two groups with different surgical interventions
Evacuation (43)Group 1 Evacuation with resection and repair (45)Group 2 P-value
Duration of ventilator support (days) 13.61 ± 14.88 7.18 ± 8.05 0.015
Duration of chest tube use 16.65 ± 12.56 11.24 ± 4.55 0.010
Positive microbial cultures in sputum 28 (65.1%) 16 (35.6%) 0.006
Positive microbial cultures in pleural effusions 20 (46.5%) 8 (17.8%) 0.004
Secondary VATS 6 (14.0%) 2 (4.4%) 0.121
ICU LOS 16.60 ± 16.90 8.11 ± 4.91 0.003
In-hospital LOS 34.07 ± 24.23 19.38 ± 11.39 0.001
Mortality 2 (4.7%) 0 0.143
LOS: length of stay; ICU: intensive care unit.
Eight patients had postoperative complications with reaccumulating pleural collections. Six patients were Group 1 and the others were Group 2. All of them underwent a secondary VATS procedure for drainage. In Group 1, the percentage of this complication was higher than in Group 2, but without statistical significance (14.0 vs 4.4%, P = 0.121). There were several small surgical complications after VATS in both groups. Two in Group 1 and 3 in Group 2 were complicated with wound oozing. All of them were treated successfully with compression or resutured. Only 1 patient in Group 2 had lung parenchymal injury due to the instrument being introduced into the pleural cavity. This complication was treated with auto-stapler suturing immediately without further complications. Eight patients underwent a secondary VATS procedure. All of them underwent evacuation procedures. There was no complication after the secondary VATS procedure.
Two patients expired in this study; both were from Group 1. These 2 patients expired by severe infection after trauma. One patient had a head injury with subarachnoid haemorrhage. This head injury induced aspiration pneumonia, which worsened the lung infection. The other patient was elderly, over 80 years of age. Post-traumatic pneumonia leading to sepsis was the main reason for his death. Although no patient expired in Group 2, there were no statistical differences in mortality between the two groups.