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DOI: 10.1055/a-1957-5511
Videoassistierte Thorakoskopie (VATS) beim Thoraxtrauma
VATS in Thorax Trauma![](https://www.thieme-connect.de/media/zblchir/202301/lookinside/thumbnails/10-1055-a-1957-5511_zbc1794-1.jpg)
Zusammenfassung
Seit Anfang der 90er-Jahre des letzten Jahrhunderts wird die videoassistierte Thorakoskopie (VATS) in zunehmendem Maße für eine Vielzahl von Indikationen in der Behandlung des Thoraxtraumas eingesetzt. In dieser Zeit hat sich die Prämisse für den Einsatz der Thorakoskopie nicht geändert. Ihr Einsatz wird durchgehend nur für respiratorisch und kreislaufstabile Patient*innen mit einem Thoraxtrauma empfohlen. Um die Indikationen der VATS für den Einsatz beim Thoraxtrauma zu definieren, hat die Unter-AG Lungenverletzung als Teil der interdisziplinären AG Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und der Deutschen Gesellschaft für Unfallchirurgie (DGU) Behandlungsempfehlungen auf der Basis einer aktuellen Literaturrecherche (angelehnt an die PRISMA-Checkliste/hier: MEDLINE via PubMed von 1993 bis 2022) erarbeitet. In der vorliegenden Arbeit wurden nach Sichtung der recherchierten Literatur die Indikationen für die VATS in der Versorgung des Thoraxtraumas identifiziert, um klinische Anwendungsempfehlungen für den Einsatz der VATS beim Thoraxtrauma zu formulieren. Nach der Analyse von 1679 gefundenen Literaturhinweisen verblieben insgesamt 4 randomisierte kontrollierte Studien (RCTs), 4 klinische Studien sowie 5 Metaanalysen oder systematische Reviews und 39 Reviews, die aufgrund der geringen Evidenz der vorliegenden Literatur keinen höheren Empfehlungsgrad als konsensuelle Empfehlungen erlauben. In den letzten 30 Jahren haben sich die Stabilisierungsmöglichkeiten in der Versorgung von Traumapatient*innen deutlich verbessert, sodass die Indikationen zum Einsatz der VATS zunehmend erweitert werden konnten. Auch die seit mehr als 50 Jahren bestehende Empfehlung, Traumapatient*innen bei einem initialen Blutverlust ≥ 1500 ml über die liegende Thoraxdrainage oder bei einem fortwährenden Blutverlust ≥ 250 ml/h über 4 h zu thorakotomieren, hat sich mit den heutzutage besseren Stabilisierungsmaßnahmen relativiert. Für instabile/nicht stabilisierbare Patient*innen mit einer notfallmäßig zu versorgenden Thoraxverletzung ist die Thorakotomie weiterhin die Methode der Wahl, während die VATS in der Diagnostik und Therapie stabiler Patient*innen mit einem penetrierenden oder stumpfen Thoraxtrauma für eine Vielzahl von Indikationen empfohlen wird. Indikationen für die VATS sind der persistierende Hämatothorax, die Sanierung von Verletzungen und Blutungen an Lunge, Zwerchfell, Thoraxwand und anderen Organverletzungen sowie in der Sekundärphase die Therapie der thorakalen Verletzungsfolgen (Empyem, persistierende pulmonale Fistelung, infizierte Atelektase etc.).
Abstract
Since the early 1990s, video-assisted thoracoscopy (VATS) has been increasingly established for a variety of indications in the treatment of patients with thoracic trauma. During this time, one premise for the use of thoracoscopy has not changed. Its use is consistently recommended only for trauma patients with stable circulation and respiration. To define the indications of VATS for use in thoracic trauma, the Pulmonary Injury Group – as part of the Working Committee for Thoracic Trauma of the German Society for Thoracic Surgery (DGT) and the German Society for Trauma Surgery (DGU) – has developed treatment recommendations based on a current literature review (based on the PRISMA Checklist/here: MEDLINE via PubMed from 1993 to 2022). In the present study, after reviewing the available literature, the indications for VATS in the care of thoracic trauma were identified, in order to formulate clinical recommendations for the use of VATS in thoracic trauma. The analysis of 1679 references identified a total of 4 randomised controlled trials (RCTs), 4 clinical trials, and 5 meta-analyses or systematic reviews and 39 reviews, which do not allow a higher level of recommendation than consensual recommendations, due to the low evidence of the available literature. Over the past 30 years, stabilisation options in the care of trauma patients have improved significantly, allowing expansion of indications for the use of VATS. Moreover, the recommendation for more than 50 years to thoracotomise trauma patients in case of an initial blood loss ≥ 1500 ml via the inserted chest drainage or in case of continuous blood loss ≥ 250 ml/h over 4 h is now only relative with today’s better stabilisation measures. For unstable/non-stabilisable patients with a thoracic injury requiring emergency treatment, thoracotomy remains the method of choice, while VATS is recommended for a wide range of indications in the diagnosis and treatment of stable patients with a penetrating or blunt thoracic trauma. The indications for VATS are persistent haemothorax, treatment of injuries and haemorrhages to the lung, diaphragm, thoracic wall and other organ injuries, and in the secondary phase, treatment of thoracic sequelae of injury (empyema, persistent pulmonary fistula, infected atelectasis, etc.).
Schlüsselwörter
Thoraxtrauma - VATS - Thorakoskopie - Thoraxblutung - Lungenverletzung - ZwerchfellverletzungKeywords
VATS - thoracoscopy - thoracic trauma - thoracic hemorrhage - lung injury - diaphragmatic injuryPublikationsverlauf
Eingereicht: 27. April 2022
Angenommen nach Revision: 04. Oktober 2022
Artikel online veröffentlicht:
05. Dezember 2022
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