K. Dickinson1, D.M. Garofalo1, M. Bronsert1, Q.W. Myers1, A.R. Dyas1, C.M. Stuart1, C.H. Heron1, A. Wolf1, P. Rozeboom1, R.A. Meguid1, C.G. Velpulos1 1University of Colorado, Department Of Surgery, Aurora, CO, USA
Introduction:
Thoracic injuries account for up to 52% of trauma fatalities. Traditionally, open surgery was the only option for the management of surgical thoracic traumas, often associated with high morbidity and prolonged hospitalizations. Recently, endovascular and video-assisted thoracic surgery (VATS) have had growing popularity in trauma but are frequently reserved for less severe injuries in stable patients. The purpose of this study is to characterize the utilization of minimally invasive surgery (MIS) for trauma of increasing injury severity and identify factors influencing its utilization in a national database.
Methods:
Patients with serious, isolated thoracic injuries (Abbreviated Injury Scale (AIS) thorax (AISt) ≥3, all other AIS ≤2) were identified within the Trauma Quality Improvement Program (TQIP) from 2016-2019. We excluded resuscitative thoracotomies. Management was determined using International Classification of Disease (ICD)-10 codes, and patients were categorized into non-operative, endovascular, VATS and open surgery groups and then further split into subgroups according to AIS thorax (serious= AISt3, severe=AISt4, critical=AISt5+). Multiple logistic regression was performed to determine independent factors impacting utilization of each operative management strategy in comparison to non-operative.
Results:
In the 266,780 serious, isolated thoracic injuries identified, 10,918 (4.1%) underwent operative intervention, with 6494(59.5%) receiving open surgery and 4424(40.5%) MIS. Within the MIS group, 1993(45%) were endovascular and 2431(55%) were VATS. Injuries treated endovascularly included thoracic endovascular aortic repair (TEVAR) (31.7%) and arterial embolization(4.3%), but with most receiving fluoroscopy only(64%). Thoracic injury severity was lowest in the VATS (AISt3 66%, AISt4 28%, AISt5+ 5.8%, p<.001), intermediate in the endovascular (AISt 3: 59%, AISt 4: 30%, AISt 5+: 12%, p<.001), and highest in the open group (AISt3 46%, AISt4 39%, AISt5+ 15%, p<.001). Overall mortality was the highest in the open group 26%, followed by endovascular(4.1%) and VATS(2.1%), increasing with AISt in all intervention groups. Independent factors associated with the use of endovascular over non-operative management included race (Black and Asian individuals), obesity, self-pay, penetrating trauma, pulse, respiratory rate and injury severity score(ISS). Comparing VATS to non-operative management, these factors slightly differed, including race (Native Hawaiian), being underweight, Medicaid, penetrating trauma, pulse and ISS.
Conclusion:
MIS now comprises just under half of operative, isolated thoracic trauma, split almost equally between endovascular and VATS, highlighting the nationwide adoption of these less morbid techniques. Next steps include exploring which AIS 5+ injuries are being done using MIS and which open procedures potentially could have been done with MIS.