EARLY SURGICAL RESTORATION OF CHEST STRUCTURE IN PATIENTS WITH POLYTRAUMA
Federal Scientific Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
The proportion of thoracic injury in the general rate of injuries is 12-15 % [1, 2], and the mortality after closed chest injury (CCI) is 55-70.8 % [11, 12, 20]. In the general structure of polytrauma the chest injury is a dominating injury in 23-56.9 % of the patients. As for deceased patients, CCI is the direct cause of death in 25-50 % of the cases [5, 12].
Closed chest injury requires long term hospital and outpatient treatment, but, despite this fact, in 46-69 % of the cases the patients demonstrate some chest deformations, with disability in 39 % as result of severe closed chest injury [16]. In most cases closed chest injury with disordered integrity of rib cage is accompanied by intrapleural complications such as hemothorax, pneumothorax, pulmonary wounds and contusions [3, 5, 10, 11, 16]. The most common early complications of thoracic injuries in polytrauma are pneumonia (59.7 %), exudative pleuritic (50 %), clotted hemothorax (9.6 %) and pleural empyema (16 %) [3]. Before 60s in the previous century the main techniques for rib cage stabilizing were external splinting of the chest with transcutaneous distraction for a floating segment, fixing devices and barometric constructions. Also the authors offered multiple ways for internal and extrafocal fixation of injured ribs. The main advantages of surgical technique are good reposition and reliability of fixing the bone fragments [15]. However surgical technique is associated with some disadvantages: high injury rate, the risk of postsurgical purulence and constructive bulkiness [13, 14, 17, 18]. The improvement of the devices for ALV resulted in possible use of pneumatic stabilization for floating rib fractures by means of ALV in combination with different modes of PEEP. The advantages of this technique are improvement in oxygenation by means of increasing functional residual lung capacity [7]. The disadvantage is the risk of alveolar hyperextension with subsequent developing barotrauma. At the present time the fact of absent consolidation within 3 weeks from the fracture has been proved. Therefore, long term ALV is required [6, 9, 12, 14, 19] resulting in risk of pneumonia, burdening course of trauma, longer treatment and increasing lethality [21]. Based on the above-mentioned facts, one can observe that the problem of optimal choice of reconstructive techniques for chest structure is not solved yet.
Objective – to estimate efficiency of early surgical restoration of chest structure with use of the original fixator under thoracoscopic control in patients with polytrauma and dominating thoracic injury.
MATERIALS AND METHODS
The study included 50 patients suffered from polytrauma with dominating chest injury. The patients were treated in Clinical Center of Miners’ Health Protection during 2012-2014. The first aid teams transported 34 patients from the accident sites; 16 patients were transported from other non-specialized facilities by the instant readiness teams of the clinical center. All patients were transported within 48 hours after injuries. There were 32 men and 18 women. The patients were distributed into two groups: the main (n = 25) and the comparison group (n = 25). The random order of the equal sizes of the groups was achieved by means of block randomization. The patients were distributed into the groups depending on the chosen management for thoracic injuries. The patients of the main group (the mean age of 38 ± 2.8) received surgical restoration of chest structure with use of the original fixator (the patent of RF for useful model #126260 from 02.08.20120 [8]. The patients of the comparison group (the mean age of 41 ± 3.6) received pneumofixation with ALV in combination with PEEP mode (10-12 mbr). There was no surgical treatment for floating costal fractures in this group.
The severity of traumatic injuries was estimated with ISS. The severity of injuries was 36 ± 2.5 in the main group and 37 ± 2.1 in the comparison group. The severity of patients’ state was estimated with the modification of the classification systems by Border JR (1995) and Pappe H-C (2005) (table 1). All patients gave written consent for participation in the study. The study corresponds to the ethical standards from the local bioethics committee developed in concordance with World Medical Association's Declaration of Helsinki – Ethical Principles for Medical Research with Human Subjects 2000.
| Table 1 | ||||||||
| The modification of the classification systems by Border JR 1995 and Pappe H-C 2005 | ||||||||
During realization of the offered surgical technique for early restoration of chest structure we adhered to the following technique. First of all, all patients received medical diagnostic endovideothoracoscopy for estimation of severity of chest injuries and pleural sanitation. As for diagnostics, the most important aspects were injuries to pulmonary and mediastinal organs, that are triggers for thoracotomy, and identification of the region of the most severe injury to the ribs. The definition of the region of the most severe injury included the region of rib flotation or rib fracture with the greatest overriding of bone fragments and rib fracture resulting in lung injury. During thoracoscopy, for better visualizing, a trocar was introduced in the place of 2-3 intercostal space from the region of supposed maximal injury. The technique of surgical fixation depended on the level of rib fractures, degree of displaced fragments and the amount of fractures. The special attention was given to the costal surface; the region of the most severe injury resulting in chest structure disarrangement was identified. Lineal approach was made in the region of the most severe injury over the length of 4-5 cm. Then reposition was performed, with plate modelling in some cases. The plate was properly fixed by means of introduction of 4 locked screws (3.5 mm) through the previously drilled holes (with 3.2 mm drill, Fig. 1, 2). Upon achieving good reposition and fixation the fragments of the adjacent ribs were in position of satisfactory reposition, and intercostal muscular traction allowed supporting the fragments in correct anatomic position. The number of fixed ribs depended on the amount of fractures. Two ribs were fixed along one surface in fractures of 4-5 ribs, and 3 ribs were fixed in fractures of 6-9 ribs. In case of floating fractures with unstable segments the ribs were fixed along fracture lines in staggered arrangement, with 1-2 ribs along each line. Use of such technique allowed appropriate visualization of injuries, whereas low aggression of the technique decreased injury rate and reduced time of surgical intervention.
The efficiency of the offered technique for early surgical restoration of chest structure in patients with polytrauma with dominating thoracic injury was estimated according to its influence on duration of ALV, ICU and hospital stay, and mortality rate. Also the groups were examined for amount of pulmonary complications.
The statistical analysis was performed with Microsoft Excel 2007 and Statistica Trial (12.0). The variables were described as mean (M) and standard error in mean (m). Student’s test was used for estimation of the results. P ≤ 0.05 was considered as critical level of significance.
RESULTS AND DISCUSSION
The values of ALV duration in the main group were significantly lower in comparison with the control group (5.2 ± 1.48 and 12.4 ± 1.5 bed-days correspondingly, p < 0.05). Also there were statistically significant differences according to duration of hospital treatment: the main group – 21.7 ± 2.5 bed-days, the comparison group – 31.4 ± 3.6 bed-days (p < 0.05). The duration of treatment in ICU was 11.3 ± 2.3 bed-days in the main group and 14.3 ± 1.6 bed-days in the comparison group; there were no statistically significant intergroup differences (p > 0.05).
Such pulmonary complications as tracheobronchitis and pneumonia were 40 % lower in the main group than in the comparison group (table 2).
Table 2
Pulmonary complications in patients with dominating thoracic injury in the examined groups
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According to the mortality analysis, 3 patients (12 %) died in the main group, and 5 patients (20 %) in the comparison group. Multiple organ dysfunction was the cause of death in all patients.
We believe that decreasing amount of pulmonary complications is related to early surgical reconstruction of chest structure, which, in its turn, significantly reduced ALV duration in patients with polytrauma, and, as result, decreased possibility of pulmonary complications (ventilator-associated pneumonia, purulent endobronchitis). That is why we found significantly smaller amount of pulmonary complications in the main group, as well as reduction of treatment period and decreasing mortality.
All patients were followed up at outpatient stage and during the following 6 months. The main group did not show any postsurgical infectious complications for the chest and displacement of metal constructs.
The clinical case of the patient with polytrauma and dominating thoracic injury.
The patient Yu., 1961 year of birth, was admitted to the clinic 7 hours after trauma. He suffered from industrial accident – falling of a heavy metal object. The first aid was realized in the level I trauma center (primary surgical processing for the wound). The reanimobile with the special team transported the patient to Clinical Center of Miners’ Health Protection in Leninsk-Kuznetsky. The transportation lasted for 3 hours. The distance was 220 km. Transportation included realization of intensive care procedures according to the algorythms developed in our clinic [4]. The state of the patient was subcompensated according to Pape scale. ISS was 36. On the basis of the data of clinical examination, laboratory, instrumental and radiologic methods (Fig 3, 4) the diagnosis was made: “Polytrauma. Closed complicated fracture of the ribs 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 to the left with flotation of the ribs 3, 4, 5, 6, 7. Closed complicated fracture of the ribs 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 to the right with flotation of the ribs 4, 5, 6, 7. Bilateral pneumothorax, bilateral hemothorax. Heart contusion. Contusion of both lungs. ARDS of degree 2. Closed abdominal injury – rupture of the right cupula of the diaphragm, the rupture of the right liver lobe and spleen. Closed fracture of lateral parts of sacrum to the left at the level of S1-S3 without displaced fragments. Traumatic shock of degree 1”.
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Figure 3 The chest X-ray image of the patient Yu. after admission
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Figure 4 The chest CT image of the patient Yu. after admission |
The patient was emergently admitted to the surgery room. The following surgical interventions were performed: diagnostic laparoscopy, laparotomy, suturing for the right cupula of the diaphragm, splenectomy. Bilateral draining of pleural cavities was performed. The drains were connected to the passive aspiration system according to Bulau-Petrov. The further treatment was realized in the intensive care unit. In 12 hours after preliminary presurgical preparation the following surgical interventions were realized: endovideothoracoscopic revision, pleural cavity sanitation to the left. The regions of the maximal injury to the chest resulting in its structure disarrangement were identified. Then in 5th intercostal space the skin incision was made (about 5 cm), and the following procedures were performed: opened reposition, screw and plate osteosynthesis of the ribs 5, 6 to the right. To the left in the 3d intercostal space the skin incision was made (about 3 cm) in paravertebral region, and the opened reposition and left costal fixation with wire and endocostal sutures was carried out. Along the 5th rib the incision (5 cm) was made, and osteosynthesis of the ribs 4, 5, 6 to the left was realized with plates and screws (Fig. 5, 6).
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Figure 5 The postsurgical chest X-ray image of the patient Yu.
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Figure 6 The postsurgical chest CT image of the patient Yu.
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In the ICU the period of ALV was 2 days, but with moderate modes of PEEP (5-6 mbr). The extubation was performed on day 3 at the background of full restoration of independent breathing and clear consciousness.
After realization of surgical restoration of chest structure (according to ECG and ECHO) the myocardial contractility was restored. The patient received daily fibrobronchoscopic sanitation. There were no respiratory complications in view of pneumonia and endobronchitis. On the day 6 the pleural drains were removed. The patient was activated and transferred to the specialized department. On 12th day after surgery the patient (in satisfactory state) was discharged for outpatient treatment. The follow up lasted for 4 months. The patient received spirography with examination of external breathing functioning. Conclusion: moderate decrease in lung capacity, moderate decrease in bronchial passability.
The patient was interviewed with SF-36. The value of physical health was 52, the mental health – 52 points. The level of pain syndrome was estimated with visual analogue scale (VAS) and it was 1 point. The control examination (4 months after surgery) showed the following moments: lung capacity within normal range, no disorders of bronchial passability. In 4 months the patient resumed his professional activity.
Therefore, early surgical restoration of chest structure by means of the offered method allowed preventing development of severe pulmonary complications, significantly reducing management period, and, in this particular case, completely restoring the life quality to the previous level.
CONCLUSION
The offered tactics of early surgical reconstruction of the chest for the patients with polytrauma and dominating thoracic injury allowed 40 % reduction of pulmonary complications, 2.4-fold reduction of ALV duration, as well as reduction of ICU stay by 21 %, hospital management duration – by 32 % and mortality – by 8 %. The offered technique requires further development for wide implementation into clinical practice.