How To Repair Pleural Tear

Eur J Cardiothorac Surg. 2022 Jul; 46(i): 107–111.

The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt breast trauma

Yi-Pin Chou,^a, ^b, ^† Liang-Chi Kuo,^c, ^d, ^† Kwan-Ming Soo,^c, ^d, ^e Yih-Wen Tarng,^a Hsin-I. Chiang,^b Fong-Dee Huang,^a and Hsing-Lin Lin^c, ^d, ^e, ^*

Yi-Pin Chou

^aDivision of Trauma, Department of Emergency, Veterans Full general Hospital, Kaohsiung, Taiwan

^bShih-Chien University, Taipei, Taiwan

Liang-Chi Kuo

^cSectionalisation of Trauma, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

^dSection of Emergency Medicine, Kaohsiung Medical University Infirmary, Kaohsiung Medical Academy, Kaohsiung, Taiwan

Kwan-Ming Soo

^cPartitioning of Trauma, Department of Surgery, Kaohsiung Medical University Infirmary, Kaohsiung Medical University, Kaohsiung, Taiwan

^dDepartment of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

^eastFaculty of Medicine, Section of Emergency Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Yih-Wen Tarng

^aDivision of Trauma, Department of Emergency, Veterans General Hospital, Kaohsiung, Taiwan

Hsin-I. Chiang

^bShih-Chien University, Taipei, Taiwan

Fong-Dee Huang

^aDivision of Trauma, Department of Emergency, Veterans General Hospital, Kaohsiung, Taiwan

Hsing-Lin Lin

^cPartition of Trauma, Department of Surgery, Kaohsiung Medical Academy Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

^dDepartment of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan

^eFaculty of Medicine, Section of Emergency Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Received 2022 Jun 20; Revised 2022 Sep 21; Accepted 2022 Sep 26.

Abstract

OBJECTIVES

Retained haemothorax and pneumothorax are the most mutual complications later on edgeless chest traumas. Lung lacerations derived from fractures of the ribs are commonly found in these patients. Video-assisted thoracoscopic surgery (VATS) is normally used every bit a routine procedure in the treatment of retained pleural collections. The objective of this written report was to find out if at that place is any advantage in calculation the procedure for repairing lacerated lungs during VATS.

METHODS

Patients who were brought to our hospital with blunt breast trauma were enrolled into this prospective cohort study from January 2004 to December 2022. All enrolled patients had rib fractures with type III lung lacerations diagnosed by CT scans. They sustained retained pleural collections and surgical drainage was indicated. On i group, but evacuation procedure past VATS was performed. On the other group, not only evacuations simply also repair of lung injuries were performed. Patients with penetrating injury or edgeless injury with massive bleeding, that required emergency thoracotomy, were excluded from the written report, in addition to those with cardiovascular or oesophageal injuries.

RESULTS

During the study period, 88 patients who underwent thoracoscopy were enrolled. Amidst them, 43 patients undergoing the uncomplicated thoracoscopic evacuation method were stratified into Group 1. The remaining 45 patients who underwent thoracoscopic evacuation combined with resection of lung lacerations were stratified into Group 2. The rates of post-traumatic infection were higher in Group 1. The durations of chest-tube drainage and ventilator usage were shorter in Group ii, as were the lengths of patient intensive care unit of measurement stay and hospital stay.

CONCLUSIONS

When compared with unproblematic thoracoscopic evacuation methods, repair and resection of the injured lungs combined may result in better clinical outcomes in patients who sustained blunt breast injuries.

Keywords: Edgeless thoracic injury, Haemothorax, Pneumothorax, Thoracotomy, Video-assisted thoracoscopic surgery

INTRODUCTION

Blunt chest injury is the most common among all chest traumas. Most of these injuries need simply bourgeois treatments such as bed residual and pain relief. Withal, when accompanied with haemothorax and pneumothorax, additional management strategies may be needed [i, 2]. The majority of these pleural collections could be diagnosed by breast images during initial surveys and most of them could be managed successfully by tube thoracostomies simply [3–5].

Computed tomography (CT) is a tool used in surveys of chest wall injuries and lung parenchymal injuries [iii, 4, six]. There are 3 types of lung parenchymal lacerations classified by Wagner et al. [iii] co-ordinate to their locations and trauma mechanisms (Table 1). The type III laceration is located peripherally because it is usually associated with rib fractures (Fig. 1). This lesion is an important factor in the induction of haemothorax and pneumothorax [iv]. Accompanied with chest tube obstructions, retained pleural collections could occur. Further surgical intervention(southward) should be considered to forestall post-traumatic complications [vii, 8].

Tabular array i:

Wagner's classification for lung laceration diagnosed from computed tomography

Type I	Centrally located lesion, produced from shearing between the lung parenchyma and the tracheobronchial tree
Type II	Tubular lesion, located at the lower lobes; the lower breast is of a sudden compressed, squeezing the lower lobes against the vertebral bodies
Type III	Small, rounded and peripherally located, frequently associated with rib fractures and pneumothorax
Type Iv	Shearing of the lung from traction of previously formed pleuropulmonary adhesions over the parenchyma

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A patient has left-sided multiple rib fractures with haemothorax and pneumothorax. Two lacerations of the lung parenchyma could be noted on computed tomography (arrows).

Video-assisted thoracoscopic surgery (VATS) has go a practical reality in chest surgery since 1990, due to the advances in endoscopic engineering [ix–11]. Thoracic surgeons use VATS in the treatment of retained haemothorax or pneumothorax; however, some thoracic surgeons have focused on adequate drainage without management of lung parenchymal injury, while others take advanced the procedure to repair lung lacerations along with acceptable drainage. The objective of this study was to find out if there is whatever reward in repairing or resecting traumatic lung laceration to reduce the incidence of infections, with whatever benefits in terms of patient clinical outcomes.

MATERIALS AND METHODS

Patients and setting

This prospective cohort study from January 2004 to December 2022 included patients with blunt chest trauma. Patients with thoracic injuries were brought to the Kaohsiung Veterans Full general Hospital either by the emergency medical system (subsequently an accident) or transferred from another hospital after primary direction. Once admitted, patients were taken immediately to the trauma bay, surveyed by the trauma teams and managed according to Avant-garde Trauma Life Support (ATLS) guidelines. Resuscitation was initiated correct away if the patients were identified as having unstable vital signs. Those with more stable vital signs underwent detailed medical history evaluations with complete physical examinations. CT-scan was routinely performed for further evaluation of whatever lesions constitute on chest X-ray. After the completion of primary treatment in the trauma bay, patients were admitted to the intensive care unit (ICU) for further care. A written informed consent was obtained from family members of each patient. This study was approved by the Institution Review Lath of Kaohsiung Veterans General Hospital to review the medical record.

All patients included in this study were patients having type Iii lung lacerations that were diagnosed past chest CT scans during the initial assessment, and post-traumatic haemothorax or pneumothorax were managed with tube thoracostomy in the trauma bay. Claret loss was recorded initially and several hours after insertion of the chest tube. During the in-hospital flow, age, gender, trauma mechanisms, abbreviated injury score (AIS) according to the 2005 edition and length of hospitalization were all recorded. All mail service-traumatic complications were recorded, including retained thoracic collections, respiratory failure, mail service-traumatic pneumonia and post-traumatic empyema. This study excluded patients with penetrating injury or blunt injury with massive haemorrhage that required emergent or urgent thoracotomy for checking the bleeding sites. Patients who had cardiovascular or oesophageal injuries were also excluded. Although associated injuries were all recorded, those having an AIS equal to or over form three were besides excluded from this study.

Type III laceration of lung parenchyma co-ordinate to Wagner's classification is diagnosed by chest CT [3, 6]. This lesion appears as a pneumatocele located well-nigh the lung surface, and commonly has fractured ribs beside it. An air–fluid level could sometimes be seen in the lesion. In add-on to these findings, subcutaneous emphysema, haemothorax and pneumothorax could besides exist found together. Lung contusions are also diagnosed by chest CT simultaneously, and the pulmonary contusion score would exist calculated and recorded [12]. All these lung lacerations were confirmed past attending radiological physicians in our hospital. Two conditions signify massive haemorrhage in chest trauma. One is a haemothorax of >1500 ml initially drained from a tube thoracostomy. The other is the charge per unit of bleeding >250 ml/h and lasting at to the lowest degree 4 h. For both these weather condition exploratory thoracotomy is indicated to check bleeding sites, which were excluded from this report.

Post-traumatic infections were divers as positive microbial culture of sputum or pleural effusion. A retained thoracic collection was defined equally persistent haemothorax or pneumothorax that could not be drained after tube thoracostomies, lasting for at least 72 h. These findings were monitored by checking of breast 10-rays, obtained one time daily after access. Increased density and blunting of the costophrenic bending were estimated to be retained collections associated with obstacle of the chest tube and a repeat breast CT was indicated to validate the chest X-ray findings. Surgical interventions were considered in the event of retained pleural collections.

Operative methods

There are two thoracic surgery teams in our infirmary. All thoracic surgeons receive similar training programmes and the operative equipment is the aforementioned. Patients with chest injuries admitted to our infirmary were as distributed to the two thoracic surgical teams. The get-go group comprised patients admitted on odd-numbered dates and the other group comprised patients admitted on even-numbered dates. The beginning grouping underwent thoracoscopy for treating pleural collections simply past the 'evacuation' method. This method focuses on the management of pleural collections without repair of lung lesions. All patients underwent a tube thoracostomy at the ER and the incision was fabricated along the anterior axillary line at the fifth intercostal infinite. A 0° angle, x-mm thoracoscope was used. Another thoracostomy was made along the mid axillary line at the seventh intercostal space. Pleural effusion and blood clots were removed past suction tube, referred to equally the evacuation process. This procedure focuses on adequate drainage and re-expansion of the collapsed lungs. After these processes were performed, two new breast tubes were placed; 32-Fr straight and curved chest tubes were usually used. Continuous suction of the chest tubes with −15 cmH₂O was performed and they were removed when there was no air leakage or if the amount of drainage from the chest tube was <100 ml per day.

The second group underwent thoracoscopy that had small differences from the former, referred to as the 'evacuation with suture-resection' method. Equally for the first group, another thoracostomy was made at the seventh intercostal space along the mid axillary line. Subsequently this drainage, thorough inspection of the lung surface was done to look for lacerations noted at the previous chest CT, particularly the lung surface attached to the site of fractured ribs. When these lesions were institute under thoracoscopic vision, the previously used 10.v mm 0° angle telescopic was changed to a v mm 0° angle thoracoscope. A five-mm Endo-assure grasper was applied parallel to the thoracoscope through the same site. When the lesions were checked again, both edges of the lacerated lung were grasped and repaired using an endoscopic automobile-stapler (Specialist Surgical Production, Covidien Taiwan Limited) inserted through the previous thoracostomy (usually in the fifth intercostal space, anterior axillary line). As in the previous intervention for the first grouping, 32-Fr straight and curved chest tubes were placed.

All patients were admitted to the ICU postoperatively for close observation, with the duration of ventilator usage recorded. Patients were weaned off the ventilator when their vital signs were stable along with normal oximeter readings. The chest tubes were continued to continuous low-pressure suction and the volume of chest tube drainage was recorded daily. The chest tube was removed when the pleural effusion in the by 24 h amounted to <100 ml, without continuous air leakage. All patients enrolled were followed upwards at our outpatient clinics for i twelvemonth.

Statistical analysis

The objective was to determine the superiority of repairing lung lacerations, when compared with patients with no repair. A decrease of 20% in the duration of ventilator use (mean ± standard deviation (SD): fifteen ± 5) and the length of infirmary stay (hateful ± SD: 15 ± 5) was assumed. Per group, 44 patients were needed to achieve a power of eighty% to detect a departure between groups with a ane-sided level of significance of 0.025. Simple ways were used for frequency and percentages for the categorical variables, while SDs were used for the continuous variables. Categorical variables were compared by the χ ² test or Fisher'south exact exam, and numerical variables were compared by the t-test or the Wilcoxon rank-sum test. A value of P < 0.05 was considered statistically significant. Data analyses were performed using the SPSS software (Version xvi; SPSS, Inc., Chicago, IL, The states).

RESULTS

During this written report period, 1958 patients with edgeless chest injuries were admitted to our infirmary. In full, 1352 patients complicated with haemothorax or pneumothorax were treated with tube thoracostomies. Well-nigh 15% of patients (203 patients) had retained pleural collections and then that surgical interventions had to be bundled. Fourscore-8 patients having type III lung lacerations diagnosed by chest CT were enrolled, including 71 males and 17 females. There was a broad variation in the age distribution, ranging from 18 to 87 years, with a mean age of 53.57 (±16.10) years. The cohort included 54 patients with motorbike accidents, xi with walking or bicycle accidents, 12 with falls and 11 with motorcar accidents. Of these, only 7 patients had single chest trauma, while the residue had two or more than sites of injury, including 32 caput injuries, 28 abdominal injuries and 51 fractured limbs. The mean AIS of the chest was iii.25. Fourscore-five patients were admitted to the ICU for close observation.

Forty-three patients who underwent thoracoscopic evacuation methods were stratified into Group 1. The remaining 45 patients who underwent evacuation plus resection and repair by thoracoscopic methods were stratified into Grouping 2. The characteristics and demographics are listed in Table 2. The distributions of historic period and gender of the two groups were comparable, along with a comparable proportion of flail chest, number of rib fractures and mean AIS of breast. However, Grouping 2 had slightly higher grades in injury severity scores (ISSs), but there was no statistical and clinical significance (16.40 ± four.46 vs 18.07 ± 5.84, P = 0.134).

Table 2:

Comparing of patient characteristics and demographics between two groups with different surgical interventions

	Evacuation (43) Group i	Evacuation with resection-repair (45) Group ii	P-value
Age	54.95 ± xiv.87	52.24 ± 17.26	0.432
Gender (male)	34 (79.1%)	37 (82.two%)	0.708
Number of fractured ribs	5.93 ± 2.93	five.36 ± 2.52	0.327
Flail chest	18 (41.9%)	18 (forty.0%)	0.859
Patients with lung contusion involving more than ii lobes	forty (93.0%)	43 (95.six%)	0.608
Pulmonary contusion score	7.84 ± ii.79	8.47 ± 1.63	0.203
Astute respiratory failure in 4 h after trauma	19 (44.2%)	15 (33.three%)	0.296
Fourth dimension from trauma to VATS	7.30 ± vi.54	vi.31 ± 2.59	0.356
ISS	sixteen.40 ± iv.46	18.07 ± 5.84	0.134
AIS chest	3.nineteen ± 0.39	3.31 ± 0.47	0.178

The pulmonary contusion scores were calculated and recorded co-ordinate to the chest radiological images. Nearly all patients had lung contusions involving more than than two lobes of the lung (93.0 vs 95.vi%, P = 0.608) and pulmonary contusion scores were virtually equal between the two groups (seven.84 ± ii.79 vs 8.47 ± one.63, P = 0.203). Because almost patients had multiple traumas, the overall mean time from trauma to the operation was 6.79 ± 4.92 days. The timing of functioning was not statistically significant between the two groups (7.30 ± vi.54 days vs 6.31 ± 2.59 days, P = 0.356). Xxx-four patients received endotracheal tube intubation within 4 h after trauma and the percentage of immediate acute respiratory failures was nearly the same in both groups (44.2 vs 33.three%, P = 0.296).

The clinical outcomes are listed in Table 3. Post-traumatic infections occurred in 44 patients. Group i patients had more postal service-traumatic infections confirmed by higher positive microbial cultured rates in sputum and pleural effusions (65.one vs 35.six%, P = 0.006; 46.5 vs 17.8%, P = 0.004). The hateful ventilator utilization fourth dimension was 10.32 (±12.26) days. In Grouping ane, the mean ventilator usage times were longer than Grouping 2 (13.61 ± 14.88 vs 7.xviii ± 8.05 days, P = 0.015). The overall mean elapsing of chest tube usage was 13.88 (±9.70) days, with a shorter duration in Group 2 when compared with Grouping 1 (16.65 ± 12.56 vs 11.24 ± 4.55 days, P = 0.010). The overall hateful length of stay (LOS) in the ICU was 12.26 (±12.97) days, with Group two having a shorter stay in the ICU when compared with Grouping 1 (xvi.threescore ± sixteen.xc vs 8.11 ± 4.91 days, P = 0.003). The total in-hospital LOS in Grouping 2 was much shorter than for Grouping 1 (34.07 ± 24.23 days compared with 19.38 ± 11.39 days, P =0.001). The blood loss during VATS was difficult to guess due to surgical haemorrhage being mixed with retained effusions. Because no patient was converted to thoracotomy in this study, nosotros idea the blood loss in the VATS procedure was small. Group two had slightly higher evacuated volume than the other, only at that place was no statistical significance (448.37 ± 84.23 vs 470.22 ± 63.73, P = 0.175).

Table 3:

Comparison of clinical outcomes between two groups with different surgical interventions

	Evacuation (43) Group 1	Evacuation with resection and repair (45) Group 2	P-value
Duration of ventilator support (days)	13.61 ± 14.88	7.eighteen ± eight.05	0.015
Duration of breast tube use	16.65 ± 12.56	11.24 ± 4.55	0.010
Positive microbial cultures in sputum	28 (65.ane%)	16 (35.6%)	0.006
Positive microbial cultures in pleural effusions	20 (46.v%)	8 (17.8%)	0.004
Secondary VATS	6 (14.0%)	ii (four.four%)	0.121
ICU LOS	sixteen.lx ± 16.90	viii.11 ± 4.91	0.003
In-hospital LOS	34.07 ± 24.23	nineteen.38 ± 11.39	0.001
Mortality	2 (4.7%)	0	0.143

Eight patients had postoperative complications with reaccumulating pleural collections. Half dozen patients were Grouping 1 and the others were Group 2. All of them underwent a secondary VATS procedure for drainage. In Group 1, the percentage of this complication was higher than in Group ii, but without statistical significance (xiv.0 vs 4.4%, P = 0.121). There were several small surgical complications later VATS in both groups. 2 in Group one and iii in Group 2 were complicated with wound oozing. All of them were treated successfully with compression or resutured. Simply 1 patient in Grouping 2 had lung parenchymal injury due to the musical instrument existence introduced into the pleural cavity. This complication was treated with auto-stapler suturing immediately without farther complications. Eight patients underwent a secondary VATS procedure. All of them underwent evacuation procedures. There was no complication later the secondary VATS procedure.

Two patients expired in this study; both were from Grouping one. These two patients expired by severe infection after trauma. One patient had a head injury with subarachnoid haemorrhage. This caput injury induced aspiration pneumonia, which worsened the lung infection. The other patient was elderly, over lxxx years of age. Post-traumatic pneumonia leading to sepsis was the main reason for his decease. Although no patient expired in Grouping ii, at that place were no statistical differences in mortality between the 2 groups.

Discussion

Post-traumatic infections are dangerous complications of edgeless breast injuries, which could increase both mortality and morbidity [1, 2]. Retained pleural collection is one of the of import causes of induced infections. The origin of microbes is non only airways but also the epidermis carried by tube thoracostomies [7, 8, 13]. Adequate drainage accompanied with antibiotics should be performed. Since 1995, VATS has been widely applied in trauma patients as a popular method instead of secondary tube thoracostomies [ix, 14]. The principal target of VATS is evacuation of retained pleural collection [10, xi, 15]. Intrathoracic lesions without life-threatening weather are usually managed with ascertainment conservatively.

Chest CT is now a routine procedure performed for edgeless breast trauma in many hospitals. It could provide clear visualizations for chest wall and lung parenchyma injuries, including lung lacerations [4, half dozen]. Co-ordinate to the nomenclature of Wagner et al. [3], blazon III lung parenchymal laceration is highly associated with rib fractures. Well-nigh of these lesions are located at the surface of the lungs that could evolve into haemothorax and pneumothorax. However, this type of lung laceration could be confirmed easily during VATS, and usually at that place is cessation of haemorrhage at initial insertion of the thoracoscope. Rebleeding from these lesions may occur after contact with a suction tube or other endoscopic instruments. In addition, air leakage could likewise re-occur. Necrotic lung tissues or pulmonary haematomas are usually found around these lacerations.

In this written report, we found that post-traumatic infection rates were lower in the surgical resection grouping. Once the infections decreased, the ventilator usage period and LOS in infirmary could both be shortened. Although the lung lacerations could be found easily by CT or during operations, surgical repair or resections are still controversial. The endoscopic suture repair is used mainly for treating pneumothorax with continuous air leakage [v, 11]. Evacuation is still the principal method during VATS; withal, if lung lacerations are big enough to be seen in chest CT, there is high potential to induce retained pleural collection. In addition to this, necrotic lung tissue also provides a good cultural medium for bacterial growth. In combination with retained pleural collections, infection rates would be elevated. The results of the study found that the rates of positive microbial cultures including sputum and pleural effusions were both lower in Group 2. Thus, we consider that resection could prevent and decrease post-traumatic infections. Once the infections were prevented, lung functions could be restored more rapidly. Besides, in Group one, the higher infection rates also increased mortality.

In this study, we also found that the duration of breast tube usage could be decreased in Grouping ii. Surgical resection and repair of the lacerated lung could stop oozing and micro air leakage faster and hence facilitate early on removal of chest tubes. Virtually of them could be removed within one week. This is an of import factor to influence the in-hospital LOS. In Grouping 1 patients, the un-sutured lungs could produce another chance of retained pleural collections again after the first VATS evacuation. Although the incidence charge per unit of secondary retained pleural effusions had no statistical difference between the two groups, we idea Grouping one had a higher rate because of the ease of oozing from the injured lung.

In our study, about of these procedures could be finished in twoscore min. The procedures of VATS to repair and resect are not complicated. Only a few complications during VATS occurred in Group two. Well-nigh of them were related to the procedure itself, including 3 patients who had bleedings from incision wounds and ane from introduction of instruments into the lung parenchyma. The bleeding from incision wounds resolved spontaneously or was managed with tight sutures, and punctured lung parenchyma was treated with an endoscopic car-stapler during the surgery. Moreover, these visible blazon Iii lung lacerations are located about the surface of the lungs. Surgical resections of these lesions are safe, and might non influence residual lung functions.

In that location are several limitations in this study. During an 8-year period, but 88 patients were included. The example numbers were difficult to accumulate in a short time considering most edgeless chest traumas could be treated with non-surgical methods and only nigh ten% of blunt chest injuries will evolve to retained pleural collections where surgical interventions should be bundled. Nonetheless, the force of this study is that the 2 groups were divided near-randomly. All the demographics in the 2 groups were similar. Surgical timing and indications for these two groups had no differences. The only difference was that Group 2 patients had undergone surgical repair and resection of the lung lacerations. Also, to decrease the bias between the groups, patients with severe medical diseases such every bit liver cirrhosis, chronic renal failure and chronic heart–lung diseases were excluded. The gender, historic period and trauma mechanism between the two groups were matched. In addition, due to blunt trauma ordinarily resulting in multiple injuries with these conditions creating great variation between patients, the ISS and regional AIS betwixt the two groups were also matched in this report. The associated injuries that were severe enough to influence the clinical outcomes such equally patients needing emergency thoracotomy were likewise excluded. All of the above could subtract the types of patients enrolled and patient numbers. Furthermore, lung contusion is some other important factor but is difficult to quantify. Destroyed chest structures could influence lung function after trauma. The numbers of rib fractures and a flail chest are important factors in worsening the lung functions. In our study, we used the pulmonary contusion score to evaluate the condition of lung parenchymal injuries although this method may also accept bias because of subjective recognition based only on breast X-ray from chart reviews. However, all patients having haemothorax and pneumothorax that could influence the verbal judgments for the pulmonary contusion score were reviewed by a senior surgeon with the aforementioned criteria. In addition, the timing of VATS introduced for retained pleural collections is some other limitation. Although the surgical indications in our hospital are similar for all thoracic surgeons, the decision for the timing of operations is varied, and may be due to associated injuries. In this report, the hateful time from trauma to surgical intervention was seven days. The timing in Group ii was slightly shorter than the evacuation-only group. This might be due to a higher chest AIS and pulmonary contusion score in Group 2.

In conclusion, for patients with lung lacerations noted on chest CT accompanied with residual pleural collection, intervention by VATS intervention for evacuation of pleural collection with suture repair of the injured lung could provide meliorate clinical outcomes.

Conflict of involvement: none declared.

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