Is VATS approach suitable in re-operations for postoperative hemothorax after pulmonary resection? Data analysis in a big volume thoracic center

Patients from January 2006 to December 2018 in the Department of Thoracic Surgery of Shanghai Pulmonary Hospital were retrospectively analyzed. Inclusion criteria: (1)post-operative hemothorax occurred after primary pulmonary resection; (2)preoperative coagulation function was normal; (3)a re-operation was performed. Exclusion criteria: (1)incomplete clinical data; (2) thoracic re-operations for reasons other than post-operative hemothorax. Reoperation is defined as returning for surgical intervention due to post-operative excessive hemothorax from postanesthetic recovery room, the intensive care unit (ICU) or ward. The decision making of reoperation was made by the same consultant surgeon team based on the hemorrhage severity and condition of patients. A reoperation for fatal hemorrhage caused by great vessels rupture during operating room was excluded for our our comparative study. Because these catastrophic situations often ruled out a VATS attempt and immediate thoracotomy and bleeding control were often the first choice in our center. The indications for re-operation in our center were summarized as follows [4, 8, 9]: (1)hemodynamic instability (shock symptoms)caused by post-operative hemothorax; (2) continuous chest drainage ≥ 200 ml/h for more than 3 h or continuous chest drainage ≥ 100–150 ml/h for more than 5 h; (3)hemoglobin of the drainage was up to 60 g/L; (4) tension hemothorax due to post-operative hemothorax; (5)X-ray indicated massive hemotoma in chest cavity after a series of conservative treatment. In this study, causes of hemothorax were divided into 3 groups according to the sources of hemorrhage: arterial hemorrhage, venous hemorrhage and capillary hemorrhage [9] (See Classification in Table 1). This study was approved by the review board of our hospital, and the requirement for informed consent for the use of patients’ medical record was waived. All methods were performed in accordance with the Declaration of Helsinki.

All patients were in lateral decubitus position and underwent single-lung anesthesia with double-lumen endotracheal intubation. VATS procedure was first introduced for re-exploration for post-operative hemothorax in 2012 in our center. Generally, the incision length for re-operation was about 2–5 cm in the complete thoracoscopic group, which were performed under non-direct view without intercostal rib spreading. The thoracoscopic port location was determined by the primary surgical operation. A single incision (about 3 cm) was made through the 4/5th intercostal space in uni-portal VATS. While in multi-portal VATS, the observation port and operation port were selected in 7th and 4th intercostal space or 8th and 5th intercostal space respectively. In open thoracotomy reoperation group, a conventional posterolateral incision (about 25–30 cm) was made through the 4/5th intercostal space and operation was performed under direct vision and hand control. VATS-assisted procedure in our study was defined as video-assisted mini-thoracotomy, in which procedure surgical operation were carried out using a combination of direct vision and video-assistance. Cases underwent either complete VATS exploration or VATS-assisted reoperations were classified as VATS reoperation group in our study. Hemostasis methods were selected according to the surgical situation, including electrocoagulation, ligation of vessels, suture, and other physical or chemical methods. In our study, surgical reoperation beyond 48 h after the primary surgical procedure was defined as delayed exploration.

Post-operative complications were defined as all complications occured during or after hospitalization. All complications were evaluated and defined according to the Clavien-Dindo classification of surgical complications [10]. Complications requiring any drug or invasive intervention are defined as grade 2 or higher. Post-operative death is defined as any cause of death within 30 days after surgery.

Data on patient's sex, age, Charlson comorbidity index (CCI), the durations of chest-tube drainage, post-operative hospital stay and major post-operative complications were collected. Demographic data and results were calculated using SPSS 23.0 software (SPSS Inc, Chicago, IL). T-test was used for continuous variables of normal distribution, while Mann–Whitney U-test was used for variables of non-normal distribution. The Pearson x² test or the Fisher exact test, when appropriate, was used to compare proportions; a value of P < 0.05 was considered statistically significant.

In recent years, minimally invasive procedure has developed rapidly and become as mainstream approach especially in thoracic surgery [12‐14]. Improvements in equipment and technology have made it possible to perform minor and major pulmonary resections by complete VATS: such as lung biopsy, wedge resection, sleeve resection and even pneumonectomy. However, the application of VATS procedure in thoracic emergency events (massive thoracic bleeding or hemopneumothorax) is rarely reported. Solaini and Joshi et al. [15, 16] firstly reported that thoracoscopic techniques offered a better visual field and a better post-operative recovery in surgical treatment for traumatic hemopneumothorax. Our results had also confirmed a superior value of complete VATS approach in reoperation for post-operative massive hemorrhage. Under a similar severity of emergency situation, the thoracoscopic group obtained certain hemostasis effect without another massive bleeding after reoperations compared with open group. Our study has also indicated significantly less complications (22.6% vs 40.4%, P = 0.039) and shorter length of chest drainage and hospital stay in thoracoscopic reoperation group, which was consistent with the above literatures [17].

The decision for reoperation depends on effective post-operative monitoring and surgeons’ experience and the indications and timing of these reoperations varied greatly between different centers [18, 19]. Karthik et al. [20] and Choong et al. [21] respectively analyzed time-related risk factors of re-operation for massive post-operative hemothorax after cardiac surgery, suggesting that a delayed reoperation beyond 12 h might increase post-operative complications by nearly threefold (29% vs 7%, P < 0.05). In our study, the time from indication to re-operation in delayed group is significantly longer than that in non-delayed group. As a resut, the incidence rate of complications above Grade 2 in the delayed reoperation group was significantly higher than that in the non-delayed group (43.8% vs 28.6%, P = 0.047), which was consistent with the literature. Due to the fact that the majority of thoracic post-operative hemothorax were caused by arterial hemorrhage (64.9%, 74/114), delayed detection and postponed reoperation resulted in rapid blood loss and unstable hemodynamics, than unnecessary complications even after conservative treatments. In this respect, early detection of post-operative hemothorax and timely surgical intervention is critical for good recovery.

This is a retrospective study with inevitable selection bias. Heterogeneous hemorrhage causes and differentiated treatment for post-operative hemothorax made it complicated for data analysis. In addition, various patients’ conditions were also complex and heterogeneous, which could not be fully randomized to conduct a sufficient comparison. Moreover, severity of emergency situation could not be evaluated precisely without including data of blood coagulation and hemodynamic parameters during the reoperations.