Time Matters: Early Video-Assisted Thoracoscopic Surgery Reduces the Risk of Post-Operative Empyema in Patients with Thoracic Trauma

Authors:
Fabiana C Sanchez, Grace M Niziolek, Grant V Bochicchio, Jason A Snyder, Leonardo J Diaz Gandica, Lindsay M Kranker, Marco J Henriquez, Marguerite W Spruce, Melissa Canas, Michael W Alchaer, Ricardo A Fonseca

Body of Abstract:
Background:
Despite having a low incidence in the adult trauma population, empyema remains a serious infectious complication with multiple etiologies and risk factors. Early Video-Assisted Thoracoscopic Surgery (VATS) may reduce the risk of empyema by facilitating early drainage and preventing infection progression. This study compares the incidence of post-operative empyema in trauma patients undergoing early versus late VATS, aiming to assess the impact of timing on the risk of developing an empyema.
Methods:
This study was conducted using an urban level 1 trauma registry, querying all patients with thoracic trauma who underwent VATS from May 2018 to June 2024. We included patients who underwent VATS for retained hemothorax or lung entrapment. Patients undergoing VATS for pre-existing empyema, bleeding control, diaphragmatic injuries, or rib plating alone were excluded. Early VATS was defined as surgery performed within 4 days of admission; a cut point utilized in the EAST hemothorax guidelines. Post-operative empyema development was confirmed by imaging evidence, clinical evaluation, and/or microbiology findings. Comparative analyses were conducted using chi-square tests and independent samples t-test; a multivariate regression model was used to assess the risk of empyema controlling for penetrating injuries, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) Chest score, chest tube placement after 24 hours from admission, retained hemothorax, non-chest surgeries before VATS, and VATS timing.
Results:
A total of 87 patients were identified, with 34 (39.1%) undergoing early VATS and 53 (60.9%) undergoing late VATS. Post-operative empyema was identified in 3 (8.8%) patients in the early VATS group compared to 19 (35.8%) in the late VATS group (p=0.005). The early and late VATS groups had statistically-similar age, gender, race, BMI, and ISS. Patients in the early VATS group had higher AIS chest scores (3.0 vs 2.7, p=0.013) and fewer ventilator days (5.5 vs 6.5, p<0.001) than the late group. Early VATS was also associated with a shorter hospital length of stay (12.8 vs 21.9, p=0.001). The late VATS group exhibited a trend toward higher conversion to open thoracotomy (9.4 vs 2.9%, p=0.244). Multivariate logistic regression analysis demonstrated that late VATS independently increases the risk of empyema (OR=6.099, p=0.011, 95% CI:1.51–24.67). Conclusions: In trauma patients with thoracic injuries, early VATS intervention (≤4 days) is associated with better clinical outcomes, including a significantly lower incidence of empyema, fewer ventilator days, and shorter hospital stays when compared to late VATS. These findings highlight the potential benefits of timely surgical management in thoracic trauma, particularly for post-traumatic retained hemothorax. However, further prospective studies are needed to determine whether these associations reflect causation or correlation.