|Year : 2016 | Volume
| Issue : 1 | Page : 8-11
Damage Control Thoracic Surgery
James V O'Connor
Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
|Date of Web Publication||15-Nov-2016|
James V O'Connor
Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
Source of Support: None, Conflict of Interest: None
Damage control as a management strategy for the most severely injured and metabolically depleted patients was first utilized for penetrating abdominal trauma. The principles are early hemorrhage control, limiting enteric contamination, resuscitation in the intensive care unit and, a delayed, definitive re-operation when normal physiology is restored. Since its initial use over two decades ago, the principles of damage control have been successfully utilized in the management of vascular and orthopedic injuries, and more recently in volume resuscitation. There has been a slower adoption of damage control approach to thoracic trauma, primarily due to concerns of cardiac tamponade and impaired pulmonary physiology, both the result of packing the pleural space. This review article describes philosophy, techniques and outcomes of damage control thoracic surgery.
Keywords: Aorta, chest injuries, damage control surgery, esophagus, heart, injuries, lungs, mediastinum
|How to cite this article:|
O'Connor JV. Damage Control Thoracic Surgery. J Cardiothorac Trauma 2016;1:8-11
| Introduction|| |
The prevalent use of damage control surgery has transformed the operative management of critically injured patients with severe metabolic depletion. The concept of damage control is derived from the naval doctrine of the same name, whose tenets include keeping essential shipboard functions operating allowing ships to "fight hurt."  The landmark article on damage control was by Rotondo et al. in 1993. This seminal publication described a survival benefit for patients presenting with exsanguination abdominal trauma managed using damage control principles.  Prior to this article, there were some who advocated abbreviated or truncated laparotomy with a planned re-operation.  Nevertheless, Rotondo's article initiated a new era in trauma surgery, with damage control being a widely adopted technique. Although initially utilized for abdominal trauma, these principles have been successfully applied to orthopedic, vascular, and thoracic injuries, as well as resuscitation. ,,,,
The rational for damage control is to limit operating time in the physiologically impaired patients with marginal reserve and limited compensatory ability. The sequela of exsanguinating hemorrhagic shock is profound metabolic acidosis, hypothermia, and coagulopathy, all of which are independent predictors of mortality. ,, Therefore, the principles of damage control surgery directly address these effects. These principles are hemorrhage control, control of contamination, limited operative time, resuscitation in the Intensive Care Unit (ICU), a planned, delayed re-exploration, and, if needed, delayed reconstruction. Hemorrhage control is the first priority; named vessels can be shunted or, if amenable, expeditiously repaired. Smaller vessels can ligated or tamponaded with packs. Contamination is controlled with rapid bowel resection using surgical staplers and leaving the bowel in discontinuity. Resuscitation in the ICU is directed at addressing the metabolic derangements including correction of coagulopathy and restoration of normal acid/base status and normothermia. The timing of the planned, delayed re-operation is optimally performed when homeostasis has been restored. Some of the considerations which influence the decision to perform damage control are pH <7.2, temperature <35°C, massive transfusion (>10 units packed red cells), coagulopathy, competing priorities with multiple cavitary injuries, and an operative time >90 min. These are meant to be guidelines, not absolute rules. Individualizing care for a specific patient, an experienced clinician, and sound surgical judgment is imperative in the decision-making process.
The vast majority of thoracic injuries can be managed nonoperatively. While only 20% of thoracic injuries require operative intervention, the magnitude, diversity, and complexity of the injuries can be significant and challenging. The overall published mortality is approximately 30%, and it increases with the extent of pulmonary resection and it is higher with blunt trauma. A Western Trauma Association Multicenter retrospective study of 143 patients operated for traumatic lung injury demonstrated an increased mortality with blunt injury or hypotension on admission. In addition, mortality increased with the extent of pulmonary resection; tractotomy 13%, wedge resection 30%, lobectomy 45%, and pneumonectomy 50%.  A review of National Trauma Data Bank of 669 patients requiring lung resection reported an overall mortality of 32% and a stepwise increase in mortality with the magnitude of lung resection; wedge resection 22%, lobectomy 48%, and pneumonectomy 62%. The authors also reported the mortality with isolated lung injury: Wedge resection (19%), lobectomy (27%), and pneumonectomy (53%).  In a smaller, retrospective study of 43 patients with penetrating trauma, the mortality for lobectomy and pneumonectomy was 38% and 66%, respectively. 
Taken in aggregate, these studies and others emphasize the considerable mortality and morbidity of emergent thoracotomy with lung resection for trauma. There are several important factors which impact these findings. First, as mentioned, the vast majority of chest injuries do not require operative intervention and are successfully managed with appropriate analgesia, aggressive chest physiotherapy, supplemental oxygen, and tube thoracostomy. Therefore, surgery is performed on those patients with more severe injuries or in hemorrhagic shock. Second, the step-wise increase in mortality with more extensive pulmonary resection reflects the severity of injury. A peripheral lung injury is amenable to wedge resection whereas a hilar injury will require lobectomy or pneumonectomy. Third, the majority of the published reports do not include physiologic data, which have a profound impact on mortality. Finally, concomitant, extrathoracic injuries will also adversely influence the mortality.
The high mortality associated with emergent thoracotomy and lung resection for trauma has led to the usage of novel techniques to treat these formidable injuries. The application of damage control principles to thoracic injuries has its own unique challenges, which will be explored further.
| Damage Control Thoracic Surgery|| |
In the subsequent two decades since Rotondo's original article's abdominal damage control techniques have been widely adopted, now there is a large body of relevant literature. The history of damage control thoracic surgery is more recent and less extensive. There were pervasive concerns that mediastinal and pleural packing would result in further cardiorespiratory deterioration in an already labile and comprised patient. One of the earliest uses of mediastinal packing was to control bleeding following cardiac surgery. Packing was used in 100 patients and the bleeding was controlled in 94 patients with no further decline in cardiorespiratory function.  A subsequent study described packing to control chest wall bleeding following a pulmonary resection.  Despite these encouraging results, several reports continued to advise avoiding chest packing because of the concern for tamponade, hypercarbia, hypoxia, and elevated airway pressures. , There have been two complementary approaches to thoracic damage control: limited or abbreviated thoracotomy and thoracic packing. Pulmonary tractotomy is an effective technique to control parenchymal bleeding and air leaks while avoiding a formal, anatomic pulmonary resection. , In a small, retrospective study, both mortality and morbidity were improved with nonanatomic compared to anatomic resection. ,
Until recently, there have only been sporadic case reports or small series detailing the use of thoracic packing for damage control and its impact on cardiac and respiratory function. In one small case series, there were no adverse effects associated with packing.  Two additional, limited case series reported a mortality of 36% and 53%, without further cardiorespiratory compromise. , In fact, one study demonstrated lower peak airway pressures with chest packing and temporary chest closure.  In aggregate, these studies refute the claim that impaired cardiorespiratory function is a consequence of packing the thorax. There have been a few larger series addressing thoracic damage control. Garcia et al. reported their experience with 31 patients, all explored through an anterolateral thoracotomy and had thoracic packing and temporary chest closure.  The median injury severity score (ISS) was 26, the vast majority sustained a penetrating injury, and the overall mortality was 24%. The authors stated that the patients were physiologically exhausted as demonstrated by median base deficit of 10 and temperature of 34.9°C. A range of operative procedures were performed; tractotomy was the most frequent at 48%. Mackowski et al. described their results in 25 damage control patients, stratified by incision.  Eighteen patients had an anterolateral thoracotomy and six patients had sternotomy; all were packed and had a temporary chest closure. Both groups required massive transfusion of blood and products. The ISS was higher in the thoracotomy group (34.2 vs. 25.8), but the mortality was higher in the sternotomy cohort (50% vs. 35%). The overall mortality was 40%. No physiologic data were included in the manuscript.
Objective evidence of the degree of physiologic impairment, among other factors, is crucial in the decision to perform damage control rather than a definitive surgical procedure. Our group addressed this fundamental question.  We reported the results of 44 patients with a mean ISS of 34, 61% had a chest abbreviated injury scale ≥4, and 64% of the patients required a concomitant exploratory laparotomy. Exposure was an anterolateral thoracotomy in 69% of the patients and sternotomy in 25% of the patients. Almost three-quarters of the patients underwent a pulmonary resection, 20% had cardiorrhaphy, and 9% had great vessel injury. The patients exhibited marked physiologic derangement on admission with a mean pH of 7.07, base deficit of 11.1, lactate of 8.3 mmol/L, and INR of 1.7. Mean time to chest closure was 3 days. Complications were common, and the overall mortality was 23% with no intraoperative deaths at the index operation.
The collective experience with damage control thoracic surgery suggests that it is an effective technique to address severe chest trauma in the metabolically compromised patients. Severity of the metabolic acidosis, hypothermia, coagulopathy, magnitude of thoracic injury, time to perform definitive surgery, and presence of concomitant injuries with competing priorities are all factors to be carefully considered by the operative surgeon.
| Management of Specific Injuries|| |
Operative exposure is essential when performing a damage control thoracic procedure. There are several incisions which provide optimal exposure and can be rapidly performed. An anterolateral thoracotomy is commonly used and can be extended across the sternum as a clamshell, which affords exposure to the mediastinum and great vessels. Median sternotomy provides excellent exposure of the mediastinum and great vessels, and by incising the pleura, access to the hemithorax. A posterolateral thoracotomy, the preferred incision for elective thoracic surgery, is rarely used. Placing a hemodynamically labile patient in the lateral position may result in cardiovascular collapse. In addition, this incision provides very limited mediastinal and no contralateral thoracic exposure.
Significant hemorrhage from the chest wall is almost invariably from intercostal or internal mammary arteries, the majority of which are easily controlled. The exception is bleeding from an inferior, posterior intercostal artery. These may be challenging to ligate, given their location. Packing, topical hemostatic agents and angiographic embolization may be the preferred approach. Occasionally, a fully opened rib retractor will temporarily occlude a bleeding intercostal vessel. Removing the retractor and using handheld retractors will improve visualization of the vessel, which is then ligated. If a clamshell incision is used, it is imperative to ligate the internal mammary arteries, which may not be briskly bleeding in the hypotensive patients and therefore overlooked.
While a full discussion of cardiac injuries is beyond the scope of this review, there are several salient points. The pericardium should be widely opened and a pericardial sling may facilitate cardiorrhaphy. In decreasing frequency, the chambers injured are right ventricle, left ventricle, right atrium, and left atrium. Cardiac lacerations are repaired with nonabsorbable suture; pledgets are not mandatory and used as indicated. The curve of the needle engaging the needle at right angles to the epicardium and synchronizing suture placement to the beating heart are important technical aspects to a successful repair. The pericardium should left open, and a mediastinal drain must be placed.
Great vessel injuries are daunting. Optimal exposure is imperative and temporary control is obtained by direct digital pressure or with a vascular clamp. In a damage control procedure, it is generally unwise to attempt primary repair, unless the injury is amenable to rapid repair. With the exception of the cavae, veins can be ligated or shunted. Temporary arterial shunting, with delayed reconstruction, is a proven approach in vascular damage control. ,,
Pulmonary injures have been discussed above; however, a few pertinent technical details are relevant. Bleeding from the hilum is challenging. Rapid hemorrhage control can be achieved either by directly hilar clamping or using the hilum twist technique.  As mentioned above, most through and through lung injuries are managed by tractotomy, which is both rapid and definitive. Peripheral parenchymal injuries are appropriately handled by wedge resection; larger injures may necessitate a nonanatomic resection. Most hilar injures are not easily repaired, with the remaining options of lobectomy or pneumonectomy or hilar clamping with delayed resection. , As expected, the mortality for these procedures is high.
Larger bore chest tubes are positioned posteriorly, and a smaller mediastinal drain is placed if indicated. Laparotomy packs are placed on the pleural surfaces, which will control coagulopathic bleeding and bleeding from low-pressure vessels. A modified vacuum dressing or skin closure may be used as a temporary chest closure. , Resuscitation in the ICU is directed at correcting metabolic acidosis, achieving normothermia, and treating the coagulopathy. Blood and product transfusion may be guided by laboratory values and TEG.
Timing to definitive chest closure is variable. Rather than a predetermined time to return to the opening room for closure, the decision should be based on physiologic normalization. The goal is to return to a normal physiologic state prior to definitive surgery. When homeostasis is achieved, definitive surgery and chest closure can be performed with minimal morbidity. ,,
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Conflicts of interest
There are no conflicts of interest.
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