Download PDF
Zentralbl Chir 2023; 148(01): 74-84
DOI: 10.1055/a-1957-5511
Thoraxchirurgie
Übersicht

Videoassistierte Thorakoskopie (VATS) beim Thoraxtrauma

VATS in Thorax Trauma
Christof Schreyer
1   Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
,
Christoph Eckermann
1   Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrzentralkrankenhaus, Koblenz, Deutschland
,
Jens Neudecker
2   Klinik für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Universitätsmedizin Berlin - Charité Campus Mitte, Berlin, Deutschland
,
Lars Becker 
3   Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland (Ringgold ID: RIN39081)
,
Stefan Schulz-Drost
4   Klinik für Unfallchirurgie und Traumatologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland (Ringgold ID: RIN62491)
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Zusammenfassung

Seit Anfang der 90er-Jahre des letzten Jahrhunderts wird die videoassistierte Thorakoskopie (VATS) in zunehmendem Maße für eine Vielzahl von Indikationen in der Behandlung des Thoraxtraumas eingesetzt. In dieser Zeit hat sich die Prämisse für den Einsatz der Thorakoskopie nicht geändert. Ihr Einsatz wird durchgehend nur für respiratorisch und kreislaufstabile Patient*innen mit einem Thoraxtrauma empfohlen. Um die Indikationen der VATS für den Einsatz beim Thoraxtrauma zu definieren, hat die Unter-AG Lungenverletzung als Teil der interdisziplinären AG Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und der Deutschen Gesellschaft für Unfallchirurgie (DGU) Behandlungsempfehlungen auf der Basis einer aktuellen Literaturrecherche (angelehnt an die PRISMA-Checkliste/hier: MEDLINE via PubMed von 1993 bis 2022) erarbeitet. In der vorliegenden Arbeit wurden nach Sichtung der recherchierten Literatur die Indikationen für die VATS in der Versorgung des Thoraxtraumas identifiziert, um klinische Anwendungsempfehlungen für den Einsatz der VATS beim Thoraxtrauma zu formulieren. Nach der Analyse von 1679 gefundenen Literaturhinweisen verblieben insgesamt 4 randomisierte kontrollierte Studien (RCTs), 4 klinische Studien sowie 5 Metaanalysen oder systematische Reviews und 39 Reviews, die aufgrund der geringen Evidenz der vorliegenden Literatur keinen höheren Empfehlungsgrad als konsensuelle Empfehlungen erlauben. In den letzten 30 Jahren haben sich die Stabilisierungsmöglichkeiten in der Versorgung von Traumapatient*innen deutlich verbessert, sodass die Indikationen zum Einsatz der VATS zunehmend erweitert werden konnten. Auch die seit mehr als 50 Jahren bestehende Empfehlung, Traumapatient*innen bei einem initialen Blutverlust ≥ 1500 ml über die liegende Thoraxdrainage oder bei einem fortwährenden Blutverlust ≥ 250 ml/h über 4 h zu thorakotomieren, hat sich mit den heutzutage besseren Stabilisierungsmaßnahmen relativiert. Für instabile/nicht stabilisierbare Patient*innen mit einer notfallmäßig zu versorgenden Thoraxverletzung ist die Thorakotomie weiterhin die Methode der Wahl, während die VATS in der Diagnostik und Therapie stabiler Patient*innen mit einem penetrierenden oder stumpfen Thoraxtrauma für eine Vielzahl von Indikationen empfohlen wird. Indikationen für die VATS sind der persistierende Hämatothorax, die Sanierung von Verletzungen und Blutungen an Lunge, Zwerchfell, Thoraxwand und anderen Organverletzungen sowie in der Sekundärphase die Therapie der thorakalen Verletzungsfolgen (Empyem, persistierende pulmonale Fistelung, infizierte Atelektase etc.).

Abstract

Since the early 1990s, video-assisted thoracoscopy (VATS) has been increasingly established for a variety of indications in the treatment of patients with thoracic trauma. During this time, one premise for the use of thoracoscopy has not changed. Its use is consistently recommended only for trauma patients with stable circulation and respiration. To define the indications of VATS for use in thoracic trauma, the Pulmonary Injury Group – as part of the Working Committee for Thoracic Trauma of the German Society for Thoracic Surgery (DGT) and the German Society for Trauma Surgery (DGU) – has developed treatment recommendations based on a current literature review (based on the PRISMA Checklist/here: MEDLINE via PubMed from 1993 to 2022). In the present study, after reviewing the available literature, the indications for VATS in the care of thoracic trauma were identified, in order to formulate clinical recommendations for the use of VATS in thoracic trauma. The analysis of 1679 references identified a total of 4 randomised controlled trials (RCTs), 4 clinical trials, and 5 meta-analyses or systematic reviews and 39 reviews, which do not allow a higher level of recommendation than consensual recommendations, due to the low evidence of the available literature. Over the past 30 years, stabilisation options in the care of trauma patients have improved significantly, allowing expansion of indications for the use of VATS. Moreover, the recommendation for more than 50 years to thoracotomise trauma patients in case of an initial blood loss ≥ 1500 ml via the inserted chest drainage or in case of continuous blood loss ≥ 250 ml/h over 4 h is now only relative with today’s better stabilisation measures. For unstable/non-stabilisable patients with a thoracic injury requiring emergency treatment, thoracotomy remains the method of choice, while VATS is recommended for a wide range of indications in the diagnosis and treatment of stable patients with a penetrating or blunt thoracic trauma. The indications for VATS are persistent haemothorax, treatment of injuries and haemorrhages to the lung, diaphragm, thoracic wall and other organ injuries, and in the secondary phase, treatment of thoracic sequelae of injury (empyema, persistent pulmonary fistula, infected atelectasis, etc.).

Schlüsselwörter

Thoraxtrauma - VATS - Thorakoskopie - Thoraxblutung - Lungenverletzung - Zwerchfellverletzung

Keywords

VATS - thoracoscopy - thoracic trauma - thoracic hemorrhage - lung injury - diaphragmatic injury


Publication History

Received: 27 April 2022

Accepted after revision: 04 October 2022

Article published online:
05 December 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Schulz-Drost S, Merschin D, Gümbel D. et al. Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2020; 46: 473-485
    CrossrefPubMedSearch in Google Scholar
  • 2 Huang WY, Lu IY, Yang C. et al. Efficiency Analysis of Direct Video-Assisted Thoracoscopic Surgery in Elderly Patients with Blunt Traumatic Hemothorax without an Initial Thoracostomy. Biomed Res Int 2016; 2016: 3741426
    CrossrefPubMedSearch in Google Scholar
  • 3 Billeter AT, Druen D, Franklin GA. et al. Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review. Langenbecks Arch Surg 2013; 398: 515-523
    CrossrefPubMedSearch in Google Scholar
  • 4 Jin J, Song B, Lei YC. et al. Video-assisted thoracoscopic surgery for penetrating thoracic trauma. Chin J Traumatol 2015; 18: 39-40
    CrossrefPubMedSearch in Google Scholar
  • 5 Lodhia JV, Konstantinidis K, Papagiannopoulos K. Video-assisted thoracoscopic surgery in trauma: pros and cons. J Thorac Dis 2019; 11: 1662-1667
    CrossrefPubMedSearch in Google Scholar
  • 6 Wu N, Wu L, Qiu C. et al. A comparison of Video-Assisted Thoracoscopic Surgery with Open Thoracotomy for the Management of Chest Trauma: A Systematic Review and Metaanalysis. World J Surg 2015; 39: 940-952
    CrossrefPubMedSearch in Google Scholar
  • 7 Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung. AWMF Register-Nr. 012/019. Stand: 07/2016. 153-172. 297-315. 319-327.
    PubMed
  • 8 The Committee on Trauma 2018. ATLS® Advanced Trauma Life Support Student Course Manual. Chicago: ACS American College of Surgeons; 2018
    Search in Google Scholar
  • 9 Ben-Nun A, Orlovsky M, Best LA. Video-assisted thoracoscopic surgery in the treatment of chest trauma: long-term benefit. Ann Thorac Surg 2007; 83: 383-387
    CrossrefPubMedSearch in Google Scholar
  • 10 Cobanoğlu U, Sayir F, Mergan D. Should videothorascopic surgery be the first choice in isolated traumatic hemothorax? A prospective randomized controlled study. Ulus Travma Acil Cerrahi Derg 2011; 17: 117-122
    CrossrefPubMedSearch in Google Scholar
  • 11 Kumar S, Rathi V, Rattan A. et al. VATS versus intrapleural streptokinase: a prospective, randomized, controlled clinical trial for optimum treatment of post-traumatic residual hemothorax. Injury 2015; 46: 1749-1752
    CrossrefPubMedSearch in Google Scholar
  • 12 Meyer DM, Jessen ME, Wait MA. et al. Early evacuation of traumatic retained hemothoraces using thoracoscopy: a prospective, randomized trial. Ann Thorac Surg 1997; 64: 1396-1400
    CrossrefPubMedSearch in Google Scholar
  • 13 Hendriksen BS, Kuroki MT, Armen SB. et al. Lytic Therapy for Retained Traumatic Hemothorax. Chest 2019; 155: 805-815
    CrossrefPubMedSearch in Google Scholar
  • 14 Patel NJ, Dultz L, Ladhani HA. et al. Management of simple and retained hemothorax: A practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2021; 221: 873-884
    CrossrefPubMedSearch in Google Scholar
  • 15 Ziapour B, Mostafidi E, Sadeghi-Bazargani H. et al. Timing to perform VATS for traumatic‑retained hemothorax (a systematic review and meta‑analysis). Eur J Trauma Emerg Surg 2020; 46: 337-346
    CrossrefPubMedSearch in Google Scholar
  • 16 Jahresbericht 2020 – TraumaRegister DGU®. Höfer C, Lefering R. Berlin: 2020. Accessed January 21, 2021 at: https://www.traumaregister-dgu.de/fileadmin/user_upload/TR-DGU_Jahresbericht_2020.pdf
    Search in Google Scholar
  • 17 Chan KK, Joo DA, McRae AD. et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev 2020; 7: CD013031
    CrossrefPubMedSearch in Google Scholar
  • 18 Greenberg MD, Rosen CL. Evaluation of the patient with blunt chest trauma: an evidence based approach. Emerg Med Clin North Am 1999; 17: 41-62
    CrossrefPubMedSearch in Google Scholar
  • 19 Rozycki GS, Feliciano DV, Ochsner MG. et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999; 46: 543-551
    CrossrefPubMedSearch in Google Scholar
  • 20 Guerrero-Lopez F, Vázquez-Mata G, Alcázar-Romero PP. et al. Evaluation of the utility of computed tomography in the initial assessment of the critical care patient with chest trauma. Crit Care Med 2000; 28: 1370-1375
    CrossrefPubMedSearch in Google Scholar
  • 21 Okamoto K, Norio H, Kaneko N. et al. Use of early-phase dynamic spiral computed tomography for the primary screening of multiple trauma. Am J Emerg Med 2002; 20: 528-534
    CrossrefPubMedSearch in Google Scholar
  • 22 Bieler D, Franke AF, Hentsch S. et al. Gunshot and stab wounds in Germany-epidemiology and outcome: analysis from the TraumaRegister DGU®. Unfallchirurg 2014; 117: 995-1004
    CrossrefPubMedSearch in Google Scholar
  • 23 Onat S, Ulku R, Avci A. et al. Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center. Injury 2011; 42: 900-904
    CrossrefPubMedSearch in Google Scholar
  • 24 Vinck EE, Ángel EP, Barrios RV. et al. Video-Assisted Thoracoscopy For Penetrating Cardiac Box Injury in Stable Patients. Braz J Cardiovasc Surg 2021; 36: 550-556
    CrossrefPubMedSearch in Google Scholar
  • 25 Vasse M, Belaroussi Y, Avaro JP. et al. Surgical exploration for stable patients with penetrating cardiac box injuries: when and how? A cohort of 155 patients from Marseille area. J Trauma Acute Care Surg 2022; 93: 394-401
    CrossrefPubMedSearch in Google Scholar
  • 26 Bagheri R, Tavassoli A, Sadrizadeh A. et al. The role of thoracoscopy for the diagnosis of hidden diaphragmatic injuries in penetrating thoracoabdominal trauma. Interact Cardiovasc Thorac Surg 2009; 9: 195-197
    CrossrefPubMedSearch in Google Scholar
  • 27 Goodman M, Lewis J, Guitron J. et al. Video-assisted thoracoscopic surgery for acute thoracic trauma. J Emerg Trauma Shock 2013; 6: 106-109
    CrossrefPubMedSearch in Google Scholar
  • 28 Yanık F, Karamustafaoğlu YA, Yörük Y. The role of VATS in the diagnosis and treatment of diaphragmatic injuries after penetrating thoracic traumas. Ulus Travma Acil Cerrahi Derg 2020; 26: 469-474
    CrossrefPubMedSearch in Google Scholar
  • 29 Powell L, Chai J, Shaikh A. et al. Experience with acute diaphragmatic trauma and multiple rib fractures using routine thoracoscopy. J Thorac Dis 2019; 11: 1024-1028
    CrossrefPubMedSearch in Google Scholar
  • 30 Smith RS, Fry WR, Tsoi EK. et al. Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury. Am J Surg 1993; 166: 690-693
    CrossrefPubMedSearch in Google Scholar
  • 31 Alwatari Y, Simmonds A, Ayalew D. et al. Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes. Eur J Trauma Emerg Surg 2022; 48: 3211-3219
    CrossrefPubMedSearch in Google Scholar
  • 32 Aiolfi A, Inaba K, Martin M. et al. Lung Resection for Trauma: A Propensity Score Adjusted Analysis Comparing Wedge Resection, Lobectomy, and Pneumonectomy. Am Surg 2020; 86: 261-265
    CrossrefPubMedSearch in Google Scholar
  • 33 Homo RL, Grigorian A, Lekawa M. et al. Outcomes after pneumonectomy versus limited lung resection in adults with traumatic lung injury. Updates Surg 2020; 72: 547-553
    CrossrefPubMedSearch in Google Scholar
  • 34 Stephens N, Rice D, Correa A. et al. Thoracoscopic lobectomy is associated with improved short-term and equivalent oncological outcomes compared with open lobectomy for clinical Stage I non-small-cell lung cancer: a propensity-matched analysis of 963 cases. Eur J Cardiothorac Surg 2014; 46: 607-613
    CrossrefPubMedSearch in Google Scholar
  • 35 Wang Z, Pang L, Tang J. et al. Video-assisted thoracoscopic surgery versus muscle-sparing thoracotomy for non-small cell lung cancer: a systematic review and meta-analysis. BMC Surg 2019; 19: 144
    CrossrefPubMedSearch in Google Scholar
  • 36 Chou YP, Kuo LC, Soo KM. et al. The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma. Eur J Cardiothorac Surg 2014; 46: 107-111
    CrossrefPubMedSearch in Google Scholar
  • 37 Liu X, Xiong K. Surgical management versus non-surgical management of rib fractures in chest trauma: a systematic review and metaanalysis. J Cardiothorac Surg 2019; 14: 45
    CrossrefPubMedSearch in Google Scholar
  • 38 Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg 2017; 43: 163-168
    CrossrefPubMedSearch in Google Scholar
  • 39 Becker L, Schulz-Drost S, Spering C. et al. Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2022; 48: 2773-2781
    CrossrefPubMedSearch in Google Scholar
  • 40 Liu T, Liu P, Chen J. et al. A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients With Flail Chest. J Surg Res 2019; 242: 223-230
    CrossrefPubMedSearch in Google Scholar
  • 41 Wu TH, Lin HL, Chou YP. et al. Facilitating ventilator weaning through rib fixation combined with video-assisted thoracoscopic surgery in severe blunt chest injury with acute respiratory failure. Crit Care 2020; 24: 49
    CrossrefPubMedSearch in Google Scholar
  • 42 Zhang J, Hong Q, Mo X. et al. Complete Video-assisted Thoracoscopic Surgery for Rib Fractures: Series of 35 Cases. Ann Thorac Surg 2022; 113: 452-458
    CrossrefPubMedSearch in Google Scholar
  • 43 Piaricci FM. Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it?. J Thorac Dis 2019; 11 (Suppl. 08) S1061-S1069
    CrossrefPubMedSearch in Google Scholar
  • 44 Murfee JR, Pardue KE, Farley P. et al. Unexpected Diaphragmatic Hernia Among Patients Undergoing Video-Assisted Thoracic Surgery for Internal Fixation of Rib Fractures. Am Surg 2022; 88: 618-622
    CrossrefPubMedSearch in Google Scholar
  • 45 Schots JP, Vissers YL, Hulsewé KW. et al. Addition of Video-Assisted Thoracoscopic Surgery to the Treatment of Flail Chest. Ann Thorac Surg 2017; 103: 940-944
    CrossrefPubMedSearch in Google Scholar
  • 46 Wemeijer TM, Hogeboom W, Steenvoorde P. et al. Missed injuries in trauma patients: the value of a diagnostic thoracotomy or thoracoscopy during surgical stabilisation of rib fractures. Ir J Med Sci 2022; 191: 1285-1289
    CrossrefPubMedSearch in Google Scholar
  • 47 Newberry R, Brown D, Mitchell T. et al. Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians. Ann Emerg Med 2021; 77: 317-326
    CrossrefPubMedSearch in Google Scholar