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Features of chest trauma in patients admitted to the Republican Research Centre of Emergency Medicine
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Khadjibaev Abdukhakim Muminovich, Republic Research Center of Emergency Medicine, Tashkent, Uzbekistan,
MD, Phd, ScD, Professor, Director General E-mail: [email protected] Rakhmanov Ruslan Odiljanovich, MD., PhD, Senior research worker, Department of emergency surgery
E-mail: [email protected] Sultanov Pulat Karimovich, MD, Senior research worker, Department of emergency surgery
E-mail: [email protected]
Features of chest trauma in patients admitted to the Republican Research Centre of Emergency Medicine
Abstract: Obj ective of the study was to improve the results of treatment of patients with chest trauma by early and wide use of VATS. There analyzed the findings of examination and surgery cases of 1396 patients with chest trauma. They divided into two groups: 552 patients who had been made examination and traditional treatment without VATS and 844 patients who underwent VATS during primary diagnostics and surgery.
Due to VATS we were able to reveal all of the most probable variants of chest injuries and avoid useless thoracotomy. VATS prevails the other noninvasive and minimally invasive methods of diagnostic of chest trauma. VATS also allows eliminating injuries with minimal operation procedures for the patient. Postoperative complications occurred in 25.4 % patients of first group and in 10.9 % patients of second group.
VATS allows diagnosing on time the injuries of thoracic organs. Also it helps to stop bleeding, make hermetic lung ruptures and chest sanation. We can reach early activation of patients, and reduce in-hospital days by using VATS in patients with chest trauma. Surgical approach of treatment for chest trauma needs to be determined not only by the results of primary chest drainage but also by the results of VATS revision.
Keywords: chest trauma, VATS, thoracotomy, complications.
Introduction. One of the important medical and social problems in industrial countries has become an injury of people that require huge financial expenditure [3, 32; 8, 48-52]. Chest trauma takes the third place (30-40 %) after traumatic brain injury (TBI) and extremities trauma. 90 % of injured patients are able-bodied population [1, 42-45; 10, 43-44; 11, 44-50; 15, 111-114; 17, 190-195; 18, 1273-1294]. Chest trauma characterized by long term treatment and
rehabilitation with septic complications (up to 20 %) and high fatal outcomes (17-30 %) [5, 32-38; 6, 4-9; 7, 78-80; 9, 62-63; 14, 479-489; 16, 368-370].
According to literature, 15 % of died patients from chest trauma without fatal injuries died due to medical aid defects. One of them is late diagnostics of injuries in chest trauma [2, 39-43; 12, 509; 13, 328; 19, 3-9]. Poor resolution of simple X-ray of thorax does not allow estimating on time the
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chest injuries [4, 10-14; 18, 1273-1294]. Diagnostic difficulties of chest trauma lead to unreasonably conservative therapy of patients when surgery is needed. The result of this is development of severe complications and increase of death rate. Herewith, the frequency of useless thoracotomy in chest trauma ranged from 10 to 15 % [13, 328].
Objective. Improve the results of treatment of patients with chest trauma by early and wide use of videothoracoscopy (VATS).
Material and methods. There analyzed the findings of examination and surgery cases of 1396 patients with chest trauma. First group included 552 (39.5 %) patients who had been made examination and traditional treatment without VATS. Second group were 844 (60.5 %) patients who underwent VATS during primary diagnostics and surgery. There were male 1192 (85.4 %) and female 204 (14.6 %) aged between 17 to 83 years. Half of the injured patients (51.9 %) are admitted within first 6 hours. 952 (68.2 %) patients had
Fig. 1. VATS. Parietal pleura laceration
Fig. 2. VATS. Lung laceration
Fig. 3. VATS. Diaphragm laceration
blunt chest trauma and 444 (31.8 %) patients had penetrating stub-cut chest injuries.
We observed that blunt chest trauma had frequent similar localization on the right and left sides (43.7 % and 50.8 % correspondingly) whereas penetrating stub-cut chest trauma prevailed on left side (68.5 %).
Multiple traumas observed in 152 (27.5 %) patients of first group and 204 (24.2 %) patients of II group. There were a lot of cases of combination of chest trauma and TBI or fractures of extremities.
Diagnostic methods of patients with chest trauma included general clinical and laboratory examinations, US and X-ray methods, chest drainage and VATS (in II group).
Statistical analysis was performed using Statview version 5. For normally distributed data an unpaired f-test was used and for skewed data a Mann-Whitney U-test was used. X statistics were used to compare proportions in the groups. Statistical significance was assumed if P<0.05.
Fig. 4. VATS. Hemothorax
Fig. 5. VATS. Subpleural bleeding and hematoma
Fig. 6. VATS. Lung parenchyma hematoma
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Features of chest trauma in patients admitted to the Republican Research Centre of Emergency Medicine
Results and discussion. General clinical manifestations of chest trauma were pain in 1352 (96.8 %) patients, short breath in 964 (69.1 %) patients and common fatigue in 1248 (89.4 %) patients. It should be noted that every fourth injured patient (26.4 %) had a sign of lung tissue damage - blood spitting.
X-ray of thorax revealed different pathological changes in 1304 (93.4 %) patients. Thus, hemothorax was determined in 240 (17.2 %) patients, pneumothorax was in 360 (25.8 %) cases, hemopneumothorax — in 768 (55.0 %), subcutaneous emphysema of thorax — in 684 (49 %), lung contusion — in 36 (2.6 %), heart shadow dilatation — in 28 (2 %) patients and pneumomediastinum — in 28 (2 %) patients. Single rib fracture was revealed in 208 (21.9 %) patients of the first group and in 84 (18.6 %) patients of the second group. Multiple rib fractures were found in 328 (68.9 %) cases of 1 group and in 328 (72.6 %) cases of 2 group.
US of thorax and abdominal cavity were performed in 1284 (92 %) patients. The main task of sonography at chest trauma was to detect hemothorax which was revealed in 884 (68.8 %) cases. US was not informative due to subcutaneous emphysema of thorax in 104 (8.1 %) patients. Meanwhile, US allowed to identify injuries of abdominal organs in 304 (23.7 %) patients with multiple trauma.
VATS was used in second group. Indications to VATS were hemopneumothorax in 540 (64 %), hemothorax in 160 (19 %), pneumothorax in 124 (14.7 %), isolated subcutaneous emphysema without hemopneumothorax signs in 12 (1.4 %) and dilated heart borders by X-Ray in 8 (0.9 %) patients.
Table 1. - Character of injuries revealed by VATS in blunt chest trauma (n = 452)
Injuries n %
Subpleural bleeding and hematoma 452 100
Parietal pleura laceration 444 98.2
Lung laceration 408 90.3
Bulla laceration 8 1.8
Lung contusion 60 13.3
Lung parenchyma hematoma 32 7.1
Mediastinal hematoma 4 0.9
Mediastinal pleura laceration 12 2.7
Pneumomediastinum 32 7.1
Diaphragm laceration 8 1.8
Hemothorax 372 82.3
Intrapleural bleeding from: • Muscular vessels 44 9.7
• Intercostal vessels 8 1.8
• Lung lacerations 60 13.3
• Rib fractures parts 12 2.7
• Small vessels of mediastinum 12 2.7
• Diaphragm lacerations 4 0.9
Due to VATS we were able to reveal all of the most probable variants of chest trauma (fig. 1-6). It has been determined, that ribs fractures in blunt chest trauma combines with subpleural hematomas (452 cases) and parietal pleura laceration (444 cases). In all cases, when hemopneumothorax,
pneumothorax and subcutaneous emphysema were indicated for VATS, we determined lung laceration (408 patients) or bulla laceration (8 patients) (table 1).
The value ofVATS increases in penetrating chest trauma with damage of heart and diaphragm. Thus, we revealed diaphragm injures in every fourth thoracic injured patient, who underwent VATS (Table 2). In 8 cases, when clinical, X-ray, US signs were absent, VATS allowed to determine severe heart injury. It should be noted that we have done no misdiagnosing in VATS group.
Table 2. - Character of injuries revealedby VATS in penetrating stub-cut chest trauma (n = 392)
Injuries n %
Parawound subpleural haematoma 132 33.7
Rib and cartilage injury 20 5.1
Lung injury 156 39.8
Lung parenchyma hematoma and sub- 20 5.1
pleural lung bleeding
Wound and hematoma of mediastinum 8 2.0
Pericardial injury 24 6.1
Inferior vena cava injury 4 1.0
Heart injury 8 2.0
Diaphragm injury 92 23.5
Hemathorax 288 73.5
Intrapleural bleeding from: • Muscular vessels 76 19.4
• Intercostal vessels 24 6.1
• Internal thoracic artery 8 2.0
• Lung injuries 60 15.3
• Inferior vena cava 4 1.0
• Pericardial and heart injuries 12 3.1
• Diaphragm injuries 52 13.3
Chest punction (128 patients), chest drainage (400 patients) and primary wide thoracotomy with traditional surgery approach (24 patients) were used in first group (Table 3). Small hemothorax or pneumothorax up to 1/3 of lung volume was an indication for chest drainage. About half of patients (56, 43.8 %) underwent chest punction we were not able to get expected results, therefore we had to perform chest drainage in 48 (37.5 %) cases and in 8 (6.3 %) cases — wide thoracotomy as well. In recent years we have declined thoracic punction way of diagnostic and treatment of chest trauma.
In both groups primary wide thoracotomy provided adequate extensive surgical approach for reliable elimination of all revealed consequences of chest trauma, but primary VATS allowed avoiding useless thoracotomy. In all 40 cases of second group wide thoracotomy after VATS were made manipulations which are technically difficult to carry out with endoscopic technique (suturing of lung lacerations — 12, inferior vena cava injuries — 4, heart injuries — 8, pericardial injury — 16. Meanwhile, in first group we had to evacuate retained hemotorax in 12 cases of thoracotomy, suturing of superficial lung laceration in 12 cases and suturing of lung bulla laceration in 8 cases. All mentioned procedures could be performed by VATS (table 4 and fig. 7-12).
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Table 3. - Results of primary surgical treatment
Character of primary intervention n Recurrent interventions
Character n %
I group Chest punction 128 Chest drainage 48 37.5
Thoracotomy 8 6.3
Total 56 43.8
Chest drainage 400 Redrainage 8 2.0
Thoracotomy 20 5.0
VATS 12 3.0
Total 40 10.0
Thoracotomy 24
Total 552 96 17.4
II group VATS 804 Thoracotomy 4 0.6
VATS + thoracotomy 40
Total 844 4 0.5
Fig. 7. VATS. Mediastinal pleura cutting
Fig. 8. VATS. Coagulation of parietal pleura laceration
Fig. 9. VATS. Lung laceration suturing
Fig. 10. VATS. Coagulation of lung laceration
Fig. 11. VATS. Suturing of diaphragm injury
Fig.12. VATS. Elimination of retained hemothorax
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Features of chest trauma in patients admitted to the Republican Research Centre of Emergency Medicine
revealed by VATS; penetrating injuries of upper abdominal wall (4) and abdominal US scoring system (60).
We could avoid useless laparotomy in 52 (35.1 %) cases due to using laparoscopic technique: we excluded the damage of abdominal organs in 40 patients and we performed laparoscopic hemostasis successfully in 12 patients with superficial liver injury. In other cases we have made surgery by laparotomy.
Postoperative complications occurred in 140 (25.4 %) patients of first group and in 92 (10.9 %) patients of second group (Table 5).
Most of postoperative complications were eliminated conservatively or by the means of minor surgery (by pleural punctions and chest drainage). Secondary surgeries such as thoracotomy for postoperative complications were made in 28 (5.1 %) cases of first group and 4 (0.5 %) cases of second group.
In table 6 we can see comparison of two groups by the frequency of thoracotomy, duration of operative interventions and duration of chest draining, complications in early period.
None of patients in these groups had fatal outcome.
Thus, VATS prevails the other noninvasive and minimally invasive methods of diagnostic of chest trauma. VATS also allows eliminating injuries with minimal operation procedures for the patient.
Conclusions. VATS allows diagnosing on time the injuries of thoracic organs. Also it helps to stop bleeding, make hermetic lung ruptures and chest sanation. We can reach early activation of patients, and reduce in-hospital days by using VATS in patients with chest trauma. Surgical approach of treatment for chest trauma needs to be determined not only by the results of primary chest drainage but also by the results ofVATS revision.
Table 5. - Postoperative complications
Complications I group, n=552 II group, n=844
absolute % absolute %
Unspecific complications 40 7.2 44 5.2
• Postoperative pneumonia 40 7.2 44 5.2
Specific complications 100 18.1 48 5.7
• Wound infection 8 1.4 8 0.9
• Ongoing pneumothorax 56 10.1 - -
• Retained hemothorax 4 0.7 - -
• Exudative pleuritis 24 4.3 36 4.3
• Lung atelectasis 4 0.7
• Intrapleural bleeding 4 0.7 4 0.5
Total: 140 25.4 92 10.9
Table 6. - Comparison of two groups
Indication I group n=552 II group n=844 P
Frequency of thoracotomy, % 9.4 5.2 X2 = 7.12 p < 0.05
Duration of chest draining, days 4.6 ± 0.31 2.2 ± 0.32 t = 5.56 p < 0.05
Common frequency of complications, % 25.4 % 10.9 % X2 = 8.51 p < 0.05
Durations of in-patient treatment, days 8.1 ± 0.36 7.1 ± 0.27 t = 2.22 p < 0.05
Table 4. - VATS surgery in chest trauma
Surgery n %
Pleural cavity sanation 792 93.8
Haemothorax evacuation 452 53.6
Bleeding control from: 240 28.4
• muscular vessels 120 14.2
• intercostal vessels 24 2.8
• internal thoracic artery 4 0.5
• injury of lung 52 6.2
• small vessels of mediastinum 12 1.4
• Rib fractures 12 1.4
• injury of diaphragm 16 1.9
Videoassisted suturing of lung laceration 84 10.0
Incision of mediastinal pleura 20 2.4
Videoassisted suturing of diaphragm injury 8 0.9
VATS suturing of lung laceration 4 0.5
Coagulation of bullas’ rupture 4 0.5
Adequate endoscopic revision and assessment of chest trauma allowed selecting optimal surgical approach and decreasing the frequency of reoperations in 0.6 % cases in second group versus 17.4 % in first group.
Clinical experience, skills and assurance gained during this investigation by using of diagnostic and treatment opportunities of VATS allowed us to implement endoscopic technique much wider in multiple chest and abdominal trauma. In second group such combitation of trauma was in 148 (17.5 %) cases. Usually laparoscopy was performed at the second stage after VATS. Indications for laparoscopy were: penetrating diaphragm injuries (80), diaphragm lacerations (4)
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Khakimov Murod Shavkatovich, MD, Professor, Head of the Surgery Department of Tashkent Medical Academy Adilkhodjaev Askar Anvarovich, PhD, Assistant of the Surgery Department E-mail: [email protected] Yunusov Seydamet Shevketovich, Master's Degree Student of the Surgery Department
Integral assessment program for development of specific complications and tolerability of gastropancreatoduodenal resection in patients with periampullar tumors
Abstract:
Purpose: experience of radical surgical treatment of 51 patients with periampullary tumors have been analysed. Based on the original study of fatal cases of 7 patients, the integral assessment program for specific complications in
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