New England Surgical Society

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Early Video-Assisted Thoracoscopic Surgery May Reduce Hospital and ICU Length of Stay in Children With Traumatic Hemothorax
*Heather M Grant1,2,3, *Alexander Knee4, Michael V Tirabassi1,5
1UMass Medical School - Baystate Medical Center, Springfield, MA;2Institute for Healthcare Delivery and Population Science, Springfield, MA;3Tufts Clinical and Translational Science Institute, Boston, MA;4Epidemiology and Biostatistics Research Core, Office of Research, Baystate Medical Center Department of Medicine, UMass Medical School - Baystate, Springfield, MA;5Baystate Children's Hospital, Springfield, MA

Objective: To compare early and late video-assisted thoracoscopic surgery (VATS) in children with traumatic hemothorax.
Design: Cohort study.
Setting: All hospitals participating in the ACS Trauma Quality Improvement Programs (TQIP).
Patients: All hospitalized patients <18 in the 2008-2017 TQIP with traumatic hemothorax. Resuscitative thoracotomies for cardiac arrest were excluded.
Interventions: None.
Main Outcome Measures: Time to discharge, ICU LOS.
Results: 9105 patients were identified. Among blunt traumas, 4638(90.9%) patients had no procedure, 22(0.4%) early VATS(≤48-hours from admission), 33(0.6%) late VATS(>48-hours), and 407(8.0%) thoracotomy. For those with a penetrating injury, 2966(74.1%) underwent no procedure, 44(1.1%) early VATS, 58(1.4%) late VATS, and 937(23.4%) thoracotomy. Both thoracotomy groups had the lowest GCS, highest ISS, and most reinterventions.
For blunt injuries, conversion to thoracotomy was similar for early(18.2%) and late(15.2%) VATS. Compared to late VATS, adjusted risk of discharge was slightly higher for non-operative(HR=1.20; 95%CI=0.84-1.72) and early VATS(HR=1.16; 95%CI=0.66-2.03) and slightly lower for thoracotomy(HR=0.80; 95%CI=0.55-1.17). Median ICU LOS was longest for late VATS and thoracotomy(9.5 and 7.0-days, respectively). Median duration of mechanical ventilation was shortest for early VATS(1.0-days, IQR=1.0-9.0).
For penetrating injuries, conversion to thoracotomy was more common for early(31.8%) versus late(17.2%) VATS. Compared to late VATS, risk of discharge was slightly higher for early VATS(HR=1.24, 95%CI=0.83-1.86), similar for thoracotomy(HR=0.99, 95%CI=0.76-1.29), and significantly higher for non-operative(HR=1.45, 95%CI=1.12-1.89). ICU LOS was a median of 1.0 days longer for late VATS and thoracotomy compared to non-operative and early VATS. Early VATS had a median of 0.5 more ventilator days than the other interventions.
Conclusions: VATS in pediatric patients with traumatic hemothorax appears to be underutilized; it may reduce hospital and ICU LOS, particularly when performed within 48-hours of admission.


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