Video-Assisted Thoracic Surgery Evacuation of Retained Hemothorax; Timing May Not Increase Thoracoscopic Failure

Current guidelines for retained hemothorax (rHTX) in trauma patients recommend video-assisted thoracic surgery (VATS) within 4 days. However, this recommendation is currently based upon evidence from small observational studies. The aim of this study is to further evaluate the association between timing of VATS and clinical outcomes in rHTX following trauma.

Using the 2017-2019 Trauma Quality Improvement Program database, adult (≥15 years-old) trauma patients with rHTX who underwent evacuation of rHTX through VATS were included. Multivariable linear and logistic regression were used to evaluate the association between the timing of VATS and clinical outcomes. Postponing/delaying evacuation through VATS was defined in our analysis as performing the surgery 1 day later in time.

793 patients were included. VATS was performed at a median 4.5 days (Interquartile range = 2.4, 8.4). A 1.17 day increase in hospital length of stay (P = <0.001), a 0.17 day increase in postoperative hospital length of stay (P = 0.007), a 0.48 day increase in ventilation days (P = <0.001), and a 0.66 day increase in intensive care unit length of stay (P = <0.001) was found for each day that VATS was delayed. Additionally, a 1.10 odds ratio for infectious complications (P = <0.001) and a 0.96 odds ratio for discharge to home (P = 0.006) was seen for each day VATS was delayed. There was no significant association between the timing of VATS failure of VATS (defined as requiring additional procedures such as a secondary VATS or progressed to thoracotomy after initial VATS) and mortality (P > 0.05).

While delaying VATS was statistically associated with increased hospital length of stay, and other secondary outcomes, the clinical significance of the increase in these variables were less dramatic compared to the results of other studies, thus tempering the urgency of evacuation. Additionally, there was no association found between the timing of VATS and mortality, discharge disposition, or the need for additional VATS and/or thoracotomy. Therefore, in the appropriate clinical context, the evacuation of rHTX through VATS can be delayed if clinically necessary, without an associated increase in mortality or the requirement for additional procedures.