Outcomes of Video-assisted Thoracic Surgery-guided Early Evacuation of Traumatic Hemothorax: A Randomized Pilot Study at Level I Trauma Center

Abstract

Introduction:

Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous.

Methods:

Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate.

Results:

The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality.

Conclusion:

VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

INTRODUCTION

The chest is a potential space enclosing vital organs and poses a potential to harbor life-threatening injuries. Thoracic injuries constitute a major health-care burden among trauma patients and are found in almost half of the polytrauma patients.[1] These thoracic injuries are responsible for almost 20%–25% of the deaths, predominantly the prehospital deaths among trauma patients. An observational analysis published from the same center reported that chest injuries contribute to around 11% of total trauma-related deaths.[2] Besides mortality, thoracic injuries are also associated with disability. It has been observed that thoracic trauma is responsible for about 15% of loss of disability-adjusted life years. Moreover, it is the second-leading cause of death among pediatric trauma patients.[3]

The spectrum of chest injuries varies, including rib fractures, hemothorax, pneumothorax, lung parenchymal contusions, and subcutaneous emphysema. Rib fractures remain the most common entity, accounting for more than half of thoracic injuries, followed by hemothorax.[4] The incidence of traumatic hemothorax among chest trauma patients is reported to be around 21.8%.[1] The source of bleeding is often the intercostal vessels or lung parenchyma; however, sometimes injuries to great vessels or the heart are the underlying cause for traumatic hemothorax.

Traumatic hemothorax is conventionally managed with intercostal tube (ICT) thoracostomy. Although the majority of times ICT drainage is sufficient enough to drain the extravasated blood from the chest cavity, sometimes, they fail to drain out completely. The failure rate of tube thoracostomy varies and is reported in the range of 5%–30% in different series.[5] Incomplete drainage of hemothorax may lead to complications in the form of retained hemothorax, empyema, pneumonia, sepsis, lung trapping, and fibrolung. Many times, additional interventions are required to address the complication. These complications may ultimately lead to an increase in ventilator days, hospital stay, and mortality.

With the increasing evidence of complications associated with incomplete drainage of traumatic hemothorax, it is imperative that an effective and time-bound management protocol for drainage of traumatic hemothorax is essential to avoid incomplete drainage and associated complications. Management options for patients with incomplete drainage of hemothorax following tube thoracostomy include intrapleural instillation of fibrinolytic agents, video-assisted thoracic surgery (VATS) guided evacuation, and thoracotomy. However, ambiguity exists among these options in terms of indications and timing of application as well as the effectiveness of the intervention for complete drainage. Intrapleural instillation of fibrinolytics is a bedside procedure often employed as a first resort of intervention under conventional approach for cases of incomplete drainage following tube thoracostomy. However, multiple studies questioned about its effectiveness in terms of complete drainage of hemothorax and need for additional intervention.[6,7,8]

The role of VATS cannot be overemphasized in these patients with persistent hemothorax following tube thoracostomy failure. Recently, the Eastern Association for the Surgery of Trauma (EAST) had conditionally recommended in favor of VATS over intrapleural thrombolytic therapy based on existing evidence.[6] It is evident that scientific literature lacks robust evidence to dictate the mode as well as the timing for evacuation of incompletely drained traumatic hemothorax (retained hemothorax). It is intuitive that rapid recognition and early evacuation of retained hemothorax with VATS improves the patient-related outcome in terms of reduced incidence of complications, the requirement of additional interventions (such as pigtail drainage under radio imaging, thoracotomy), and shorter hospital stay.

A pilot randomized controlled clinical trial was designed with a working hypothesis of the early evacuation of traumatic hemothorax (within 48–72 h of injury) under VATS is associated with lesser incidence of complication, shorter ventilator requirement as well as intensive care unit (ICU) stay and shorter hospital stay as compared to conventional approach of intrapleural fibrinolytic. The aim of the trial was to formulate and establish a standard institutional protocol for the management of traumatic hemothorax.

METHODS

The randomized pilot trial was conducted for the duration of 2 years extending from August 2020 to July 2022 at an urban Level 1 trauma center, regularly catering a high volume of traumatic injury patients. The approval for the trial was sought from the institutional ethics committee and registered under “Clinical Trial Registry of India (CTRI)” vide CTRI/2021/03/032048 as well.[9] The primary objective was to compare the length of ventilator requirement and hospital stay between the cohorts of early VATS and the conventional approach for draining retained hemothorax.

Patients with traumatic chest injuries following either blunt or penetrating trauma presented to the emergency department (ED) and were triaged according to the severity of injury and resuscitated as per advanced trauma life support protocol.[10] Those patients falling within the age of 15–65 years of age and required tube thoracostomy for traumatic hemothorax within ED or arrived with indwelling ICT within initial 12 h of injury were recruited, subject to fulfillment of inclusion criteria. The other prerequisite for the inclusion of polytrauma patients with concomitant injuries involving multiple body regions along with the thorax was the abbreviated injury score of 3 or less in body regions other than the thoracic region. This prerequisite was framed to avoid confounding error on the length of ICU and hospital stay due to injuries involving body regions other than the chest in polytrauma patients. Patients with chronic diseases that lend them unfit for VATS or unwilling for VATS were excluded from the study. Patients received from another health-care facility under interfacility transfer with indwelling ICT for more than 48 h were also excluded from the study.

All the chest injury patients with indwelling ICT for hemothorax were evaluated at 48 h of injury for quantification of the residual amount of hemothorax using ultrasound. The ultrasound was performed by the same radiologist among all patients to minimize observer bias. The “Balik Formula” was employed for the estimation of residual hemothorax quantity.[11] Patients with incomplete drainage of hemothorax along with an estimated residual amount of blood exceeding 200 mL of blood in either of the chest cavity despite of indwelling ICT for 48 h were labeled as “retained hemothorax”[Figure 1].

Figure 1.

Ultrasound image showing persistent hemothorax as quantified by Balik formula

Patient with retained hemothorax complying with the inclusion criteria were enrolled in the trial after obtaining informed consent either from the patient or next of kin. The enrolled patients were randomization into either of two cohorts. Random sequence generation was done with a computer-generated list of random numbers obtained from a Microsoft Excel spreadsheet to ensure a block randomization of four considering the small sample size. Allocation concealment was achieved with sequentially numbered and sealed opaque envelopes.

Patients enrolled under “Early VATS” cohort underwent early evacuation within the next 24 h of diagnosis of residual hemothorax or on Day 3 (within 48–72 h) of the primary injury. Patients would be evaluated for ICT drain output, intensity of pain (pain score) as well as analgesia requirement, ventilator requirement, and need of ICU monitoring for the next 3 days of VATS. On the other hand, in “conventional approach” cohort, continuous ICT drainage was allowed for the next 24 h of diagnosis of retained hemothorax. Intrapleural instillation of fibrinolytics (streptokinase) through indwelling ICT was initiated for the next 3 consecutive days and simultaneously evaluated for ICT drain output, the intensity of pain (pain score) as well as analgesia requirement, ventilator requirement, and need of ICU monitoring. Patients in both the cohort re-evaluated for post intervention residual hemothorax (along with quantification, if present) using ultrasonography on day 7 of primary injury. The estimation was performed by the same radiologist (unaware of intervention) employing “Balik formula,” to minimize observer bias. An amount of 50 mL or less was followed by removal of ICT, however, the residual amount exceeding 50 mL was considered a failure of intervention (either VATS or fibrinolytics) and the patient was subjected to additional intervention in the form of image-guided drainage or surgical thoracotomy to address the retained hemothorax [Figure 2].

Figure 2.

Traumatic hemothorax management algorithm

The primary outcomes were measured in the form of length of hospital stay and length of ventilator requirement, as well as ICU monitoring. The secondary outcome was measures as the duration of indwelling ICT, pain score and analgesia requirement, need of further additional intervention to address retained hemothorax, and incidence of complications.

All the data collected were recorded in Microsoft Excel spreadsheet program. The data were coded and analyzed using SPSS Ver.23 statistics software (IBM Corporation, 1 New Orchard Road Armonk, New York 10504-1722, United States). The continuous variables analysed using mean/standard deviation(SD) or Median/interquartile range(IQR) based on distribution whereas frequencies and percentage(%) were used for categorical variables. Group comparisons were made using appropriate statistical tests. Statistical significance was kept at P = 0.05.

RESULTS

A total of 754 patients with thoracic trauma either isolated or polytrauma were arrived in ED during the study period. Hemothorax necessitating tube thoracostomy was diagnosed among 338 patients and subsequent ICT was inserted. ICT drainage was successful among 246 (73%) patients; however, retained hemothorax was evident in 92 (27%) patients on ultrasound performed after 48 h of injury. A total of 20 patients with retained hemothorax were recruited, whereas rests were excluded due to noncompliance [Figure 3].

Figure 3.

Consort diagram

Both cohorts were comparable in terms of demographic profile [Table 1], with male aged of 30–45 years were predominantly affected by blunt trauma. The first set of vitals on arrival to ED [Table 2] as well as injury severity [Table 3] was also comparable. The time lapse between injury and ICT insertion was comparable between the cohorts, with a mean time of 9.1 ± 2.33 h in early VATS and 8.20 ± 2.3 h in the conventional arm.

Table 1.

Comparative analysis of demographic profile

Parameters		Early VATS (n=10)		Conventional (n=10)		P
Age (mean±SD)		35.8±12.79		43.8±15.28		0.221
Gender, n (%)
Male		9 (90)		1 (10)		0.237
Female		8 (80)		2 (20)
MOI, n (%)
Blunt		8 (80)		7 (70)		0.500
Penetrating		2 (20)		3 (30)

VATS: Video-assisted thoracoscopic surgery, SD: Standard deviation, MOI: Mechanism of injury

Table 2.

Baseline physiological parameters on the primary survey at arrival in the emergency department

Variables		Early VATS (n=10)		Conventional (n=10)		P
Airway status, n (%)
Patent		10 (100)		8 (80)		0.237
Threatened		0		2 (20)
Respiratory rate (breaths/min), mean±SD		20.70±1.77		20.20±2.89		0.647
SpO2 (%), mean±SD		97.50±1.50		96.80±1.93		0.379
Mean pulse rate (beats/min), mean±SD		102.00±24.04		101.50±19.06		0.959
MAP (mm Hg), mean±SD		87.70±16.97		88.20±14.93		0.945
SI, mean±SD		0.95±0.42		0.92±0.31		0.857
Base deficit (mEq/L), n (%)
0–−2		7 (70)		6 (60)		0.5000
−2–−6		3 (30)		4 (40)
Shock present, n (%)		2 (20)		2 (20)		0.709
GCS (mean±SD)		14.80±0.632		15.00±00		0.357

SD: Standard deviation, SI: Shock index, MAP: Mean arterial pressure, VATS: Video-assisted thoracoscopic surgery, GCS: Glasgow coma scale

Table 3.

Comparative analysis of trauma scores

Trauma scores		Cohorts		n		Mean		SD		SEM		P
ISS		Early VATS		10		14.300		5.7745		1.8260		0.784
		Convention		10		15.000		5.4772		1.7321
NISS		Early VATS		10		15.200		6.9889		2.2101		0.944
		Convention		10		15.000		5.4772		1.7321
RTS		Early VATS		10		7.410		0.3071		0.0971		0.392
		Convention		10		7.500		0.1054		0.0333
TRISS		Early VATS		10		97.850		0.7397		0.2339		0.373
		Convention		10		98.130		0.6255		0.1978
AIS thorax		Early VATS		10		3.000		0.0000		0.0000		0.343
		Conventional		10		3.100		0.3162		0.1000

VATS: Video-assisted thoracoscopic surgery, ISS: Injury severity score, NISS: New injury severity score, AIS: Abbreviated injury score, RTS: Revised trauma score, TRISS: Trauma and injury severity score, VATS: Video-assisted thoracoscopic surgery, SD: Standard deviation, SEM: Standard error of the mean

The patients under the early VATS and conventional approach cohort were stayed in the hospital for a mean duration of 7.5 ± 0.85 and 9.50 ± 3.03 days, P = 0.06, respectively. The mean duration for ventilator assistance was 0.70 ± 0.48 days and 0.6 ± 1.07 days; P = 0.791 among early VATS and conventional arm, respectively, whereas the mean ICU stay was 1.3 ± 1.05 and 0.9 ± 1.44 days; P = 0.49 among early VATS and conventional cohort, respectively.

Complete drainage of a retained hemothorax (residual amount <50 mL) was achieved among 7 patients in the early VATS cohort, whereas among 3 patients in the conventional cohort with P = 0.003 as evident on ultrasonographic quantification at the completion of 72 h of intervention. Similarly, ICT was removed on the 3^rd day of intervention in 7 patients and 3 patients among early VATS and conventional cohort, respectively. The mean duration of indwelling ICT in the early VATS arm and conventional arm was 6.7 ± 1.25 and 8.3 ± 2.9 days; P = 0.12, respectively [Table 4].

Table 4.

Comparative analysis of outcome variables

Outcome variable		Early VATS cohort, n (%)		Conventional cohort, n (%)
Complete drainage of retained hemothorax (residual amount <50 mL)		7 (70)		3 (30)
ICT removal rate (after 72 h of intervention)		7 (70)		3 (30)
Duration of indwelling ICT (days), mean±SD		6.7±1.25		8.3±2.90
Additional interventions employed to address retained hemothorax (n)		1		7
Complications		Nil		4 (40)
Readmission due to thoracic cause of initial injury (within 3 months)		Nil		3 (30)

VATS: Video-assisted thoracoscopic surgery, ICT: Intercostal tube, SD: Standard deviation, n: Number of intervention

In the conventional cohort, 3 patients witnessed thoracotomy and 4 patients required image-guided pigtail placement as an additional intervention to address retained hemothorax. One patient developed pneumonia and 3 patients had empyema in the conventional arm, whereas patients in the early VATS arm did not report these complications. Similarly, no mortality was observed in both the cohorts.

DISCUSSION

The preamble of the analysis was to ascertain the most effective mode as well as the time of intervention to address incompletely drained traumatic hemothorax among the patients with chest trauma. We quantified the residual amount of hemothorax using ultrasonography with a threshold value of 200 mL after 48 h of ICT insertion. The discrepancy exists in terms of duration of indwelling ICT (ranging from 48 to 96 h), residual quantity (ranging from 200 to 500 mL or more), and diagnosing modality (X-ray or ultrasonography or computed tomography scan) to define the residual hemothorax.[7,8,12,13,14] We preferred ultrasonography as a diagnosing tool owing to its portability, easy availability, and absence of contrast or radiation risk. A meta-analysis published in 2016 reported the sensitivity and specificity of ultrasonography in the detection of hemothorax around 67% and 99%, respectively.[15] Moreover, it is safer to consider even a relatively small amount (200 mL) of residual undrained blood to be defined as retained hemothorax that too early (48 h) in the course of traumatic hemothorax to mitigate the chances of associated complications.

The ICT failed to completely drain the traumatic hemothorax in 92 (27%) patients in the present study. Similar observations have been reported by a multi-institutional prospective observational study with a failure rate of ICT alone in almost 29% of patients.[16] A retrospective review from a single center suggested that almost 18% of patients developed retained hemothorax following tube thoracostomy.[17] Similarly, Cohen et al. have also reported a failure rate of around 13% of patients, who developed retained hemothorax.[18]

It is evident in our analysis that thoracoscopic evacuation of retained hemothorax is more effective as compared to intrapleural fibrinolytics (7 [70%] vs. 3 [30%] patients; P = 0.003) in complete evacuation of undrained blood from the chest cavity. Similar observations have been reported by a retrospective review, with 17 (55%) and 30 (88%) patients having complete radiological improvement following intrapleural fibrinolytics and VATS, respectively.[7] A prospective multicenter analysis has reported that nearly 33 (30%) patients required additional intervention following VATS, whereas 10 (67%) patients needed additional intervention following intrapleural thrombolysis for retained hemothorax. Although the study has not reported the success rate of the intervention directly they used surrogate markers in the form of the requirement of additional intervention following either VATS or fibrinolytics; furthermore, both the treatment modalities were not directly compared.[8] These observations are also consistent with a randomized trial reported by Kumar et al. from a low- and middle-income country. The success rate was almost similar between the VATS and intrapleural thrombolytics cohorts (13 patients [72%] vs. 12 patients [71%]), respectively; however, basic demographic profiles, including age, mechanism of injury, and injury severity, were not compared between the cohorts.[12]

We performed VATS at a time interval of 48–72 h (within 3 days) of injury. The procedure was performed by trauma surgeons under general anesthesia with single lung ventilation, using standard three ports to visualize and access the thoracic cavity. Evacuation of residual blood and saline irrigation followed by an ICT placement was carried out under direct vision. Although early VATS-guided evacuation of retained hemothorax has been proposed by multiple studies, including a prospective randomized trial and a systematic review but lacks clarity on how early should it be performed.[7,14,19] A meta-analysis published in 2019 has reported that early VATS intervention within the first 72 h of admission is associated with a higher success rate.[20] Recently, published management guidelines from EAST have recommended performing early VATS within 4 days to reduce the chances of conversion to thoracotomy and the need for additional procedure to tackle retained hemothorax and associated complications.[6] Furthermore, it is interesting to highlight that the timing of early VATS has been reduced from earlier recommended EAST practice management guidelines of 3–7 days to within 4 days in the latest EAST guidelines.[21]

In this study, we found that early intervention under VATS is associated with shorter length of hospital stay (7.5 ± 0.85 vs. 9.50 ± 3.03 days, P = 0.06), however, the prolonged duration of ICU monitoring (1.3 ± 1.05 and 0.9 ± 1.44 days; P = 0.49), as compared to conventional cohort with intrapleural fibrinolytics. Abbreviated hospital stay associated with VATS has also been witnessed by Meyer et al. in a randomized controlled trial comprising a total of 39 patients with chest trauma, consistent with our study.[14] Smith et al. have reported a significant shorter length of hospital stay (11 ± 5 days) associated with VATS within 5 days cohort in a retrospective analysis comprising a total of 83 patients.[22] A similar trend of reduced hospital stay (9.8 ± 3.7 vs. 14.5 ± 4.2 days) was observed by Oğuzkaya et al. in a retrospective review.[7] Complete evacuation of hemothorax leads to early restoration of lung functions and reduced complications that ultimately translate into early recovery.

VATS enables the surgeon to inspect the chest cavity for collected blood as well as allows maneuvers to irrigate and completely drain the pleural cavity. Furthermore It facilitates the ICT placement under excellent vision [Figure 4]. It also provides an opportunity to look for any active source of bleeding, concomitant injuries, and abnormal pleural adhesions within the chest cavity, unlike the conventional approach of intrapleural fibrinolytics, which has been performed as a blind procedure. The shorter duration of indwelling ICT (6.7 ± 1.25 vs. 8.3 ± 2.9 days; P = 0.12) in the early VATS cohort is again consistent with the complete evacuation of retained hemothorax under vision. Similarly, a solitary case of clotted hemothorax was observed in the early VATS cohort. Saline irrigation under pressure and suction was effective in complete drainage of the clots. The employment of VATS, early in the course of traumatic hemothorax before the clotting sets in, may be a probable explanation for getting a solitary case. Furthermore, conversion to thoracotomy as an additional intervention was not observed in the early VATS cohort, unlike the conventional cohort with three patients who underwent thoracotomy following the failure of intrapleural thrombolytics to resolve retained hemothorax.

Figure 4.

Retained hemothorax observed on VATS

Although we witnessed slightly longer length of ICU stay among the early VATS cohort, the prolongation may be purely due to the institutional policy of mandatory ICU monitoring for an initial 24 h following VATS under general anesthesia. The duration of ventilator assistance was almost similar in both the cohorts (0.70 ± 0.48 days and 0.6 ± 1.07 days; P = 0.791), owing to the need for ventilator support following operative intervention in the early VATS cohort.

Limitations

Although the length of hospital stay is shorter in the early VATS cohort, it has not achieved the level of significance owing to the relatively small sample size. Moreover, being a pilot study, the inferences on the observations cannot be made with certainty. A larger trial with adequate power and a good sample size based on information acquired through the present trial is required to validate the observations.

VATS being a minimally invasive procedure, a learning curve was observed among trauma surgeons while performing VATS in the initial few cases; however, it was not measured objectively.

CONCLUSION

Majority of traumatic hemothorax can be safely managed with timely ICT drainage alone. However, about 25%–30% of patients witness failure of ICT drainage and require additional intervention to evacuate the undrained blood. VATS appears to be a promising modality for the evacuation of retained hemothorax. It is prudent to employ VATS early (within 3 days) in the course of retained hemothorax to improve the chances of complete evacuation and reduce the incidence of complications associated with retained blood within the thorax. Early evacuation under VATS is associated with a shorter duration of hospital stay, reduced span of indwelling ICT, and lesser requirement of further interventions to address the undrained hemothorax. However, no difference is found in the length of ventilator assistance, ICU monitoring, and no mortality was observed in both the cohorts.

Research quality and ethics statement

Ethical Clearance: This study was approved by Institutional Review Board, AIIMS, New Delhi (IECPG 462/23.09.2020, RT-20/21.10.2020). The authors followed applicable EQUATOR Network guidelines during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.