Videoassistierte Thorakoskopie (VATS) beim Thoraxtrauma

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

• 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 DOI: 10.1007/s00068-019-01212-3. (PMID: 31520155)
• 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 DOI: 10.1155/2016/3741426. (PMID: 27190987)
• 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 DOI: 10.1007/s00423-012-1016-7. (PMID: 23553352)
• 4 Jin J, Song B, Lei YC. et al. Video-assisted thoracoscopic surgery for penetrating thoracic trauma. Chin J Traumatol 2015; 18: 39-40 DOI: 10.1016/j.cjtee.2014.07.003. (PMID: 26169093)
• 5 Lodhia JV, Konstantinidis K, Papagiannopoulos K. Video-assisted thoracoscopic surgery in trauma: pros and cons. J Thorac Dis 2019; 11: 1662-1667 DOI: 10.21037/jtd.2019.03.55. (PMID: 31179111)
• 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 DOI: 10.1007/s00268-014-2900-9. (PMID: 25446488)
• 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.
• 8 The Committee on Trauma 2018. ATLS® Advanced Trauma Life Support Student Course Manual. Chicago: ACS American College of Surgeons; 2018
• 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 DOI: 10.1016/j.athoracsur.2006.09.082. (PMID: 17257954)
• 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 DOI: 10.5505/tjtes.2011.96777. (PMID: 21644088)
• 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 DOI: 10.1016/j.injury.2015.02.028. (PMID: 25813733)
• 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 DOI: 10.1016/S0003-4975(97)00899-0. (PMID: 9386710)
• 13 Hendriksen BS, Kuroki MT, Armen SB. et al. Lytic Therapy for Retained Traumatic Hemothorax. Chest 2019; 155: 805-815 DOI: 10.1016/j.chest.2019.01.007. (PMID: 30664856)
• 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 DOI: 10.1016/j.amjsurg.2020;11.032. (PMID: 33487403)
• 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 DOI: 10.1007/s00068-019-01275-2. (PMID: 31848631)
• 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
• 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 DOI: 10.1002/14651858.CD013031.pub2. (PMID: 32702777)
• 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 DOI: 10.1016/s0733-8627(05)70046-8. (PMID: 10101340)
• 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 DOI: 10.1097/00005373-199904000-00002. (PMID: 10217216)
• 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 DOI: 10.1097/00003246-200005000-00018. (PMID: 10834680)
• 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 DOI: 10.1053/ajem.2002.34802. (PMID: 12369027)
• 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 DOI: 10.1007/s00113-014-2647-7. (PMID: 25398509)
• 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 DOI: 10.1016/j.injury.2010.02.004. (PMID: 22081815)
• 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 DOI: 10.21470/1678-9741-2020-0361. (PMID: 34236793)
• 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 DOI: 10.1097/TA.0000000000003561. (PMID: 35125446)
• 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 DOI: 10.1510/icvts.2008.195685. (PMID: 19470502)
• 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 DOI: 10.4103/0974-2700.110757. (PMID: 23723618)
• 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 DOI: 10.14744/tjtes.2019.02682. (PMID: 32436965)
• 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 DOI: 10.21037/jtd.2019.03.72. (PMID: 31205758)
• 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 DOI: 10.1016/s0002-9610(05)80681-6. (PMID: 8273851)
• 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 DOI: 10.1007/s00068-022-01881-7. (PMID: 35084506)
• 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 (PMID: 32223808)
• 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 DOI: 10.1007/s13304-020-00727-4. (PMID: 32086773)
• 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 DOI: 10.1093/ejcts/ezu036.
• 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 DOI: 10.1186/s12893-019-0618-1. (PMID: 31615490)
• 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 DOI: 10.1093/ejcts/ezt523. (PMID: 24242850)
• 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 DOI: 10.1186/s13019-019-0865-3. (PMID: 30813961)
• 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 DOI: 10.1007/s00068-016-0721-2. (PMID: 27572897)
• 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 DOI: 10.1007/s00068-021-01864-0. (PMID: 35118558)
• 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 DOI: 10.1016/j.jss.2019.04.005. (PMID: 31100568)
• 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 DOI: 10.1186/s13054-020-2755-4. (PMID: 32050985)
• 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 DOI: 10.1016/j.athoracsur.2021.01.065. (PMID: 33675706)
• 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 DOI: 10.21037/jtd.2019.01.70. (PMID: 31205763)
• 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 DOI: 10.1177/00031348211050574. (PMID: 34839727)
• 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 DOI: 10.1016/j.athoracsur.2016.09.036. (PMID: 27939010)
• 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 DOI: 10.1007/s11845-021-02666-4. (PMID: 34091860)
• 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 DOI: 10.1016/j.annemergmed.2020.05.042. (PMID: 32807537)