Abstract | December 20, 2022

Need for Earlier Surgical Interventions in Covid-19 Positive Elderly Patients: A Description of Video-Assisted Thoracotomy

Presenting Author: Tammy Phan, MS, BS, Medical Student, 3rd Year, California University of Science and Medicine, Colton, CA

Coauthors: Natalie Liu, MS, MS3, California University of Science and Medicine, Colton, CA; Aldin Malkoc, MD, General Surgery, PGY1, Arrowhead Regional Medical Center, Colton, CA; Danny Nguyen, MD, General Surgery, PGY3, Arrowhead Regional Medical Center, Colton, CA; Jaclyn Riana Cerceo, MD, General Surgery, PGY1, Arrowhead Regional Medical Center, Colton, CA; Albert Nguyen, MD, General Surgery, PGY4, Arrowhead Regional Medical Center, Colton, CA; Olga Lebedevskiy, MD, General Surgery, PGY5, Arrowhead Regional Medical Center, Colton, CA; Bruce Toporoff, MD, Chief of Cardiothoracic Surgery, Arrowhead Regional Medical Center, Colton, CA.

Learning Objectives

  1. COVID-19 is known to cause severe medical issues in elderly patients, however, standard surgical therapies should not be delayed in the elderly populations as the risk of severe decompensation is high.

Introduction: Video-assisted thoracic surgery (VATS) is a safe and reliable option to perform various diagnostic and curative procedures. In comparison to young, healthy individuals, elderly patients are considered poor surgical candidates for intra-thoracic operations due to multiple chronic conditions, risks of general anesthesia, decreased cardiopulmonary reserve, and increased frailty. 

 

Case Presentation: A 95-year-old female presented 2 weeks after a ground-level fall with increased oxygen requirements, multiple rib fractures, and a left-sided hemothorax. Initial management with aggressive respiratory therapy, multiple pigtail chest tubes, and thrombolytics failed to drain the hematoma. To avoid further deconditioning, surgical intervention was deemed necessary. Due to extensive bleeding and visual field obstruction upon thoracoscopy, a video-assisted thoracotomy (VAT) was performed to address the retained hemothorax. Postoperatively, the patient’s clinical status was reviewed with serial imaging and oxygen saturation parameters. 

 

Final/Working Diagnosis: This study reports on an elderly patient with superimposed SARS-CoV-2 infection who underwent successful VAT after conservative measures for a retained hemothorax failed. Following conservative management, the patient’s chest x-ray showed minor improvement of her hemothorax, incentive spirometry was 500mL, and 4L of O2 via nasal cannula was required to maintain oxygen saturation >88%. Following VAT on hospital day 14, a chest x-ray showed improved left-sided consolidation, incentive spirometry improved to 750mL, and only 1-2L of O2 were required for adequate oxygen saturation. Postoperatively, the patient suffered no complications, reported minimal pain, participated more in physical therapy, and increased oral intake.

 

Outcomes and Clinical Implications: In this unique case, a SARS-CoV-2 positive, 95-year-old patient significantly improved postoperatively with minimal complications. The patient’s elderly age was a major factor in her treatment plan and pursued interventions. SARS-CoV2 was a significant social factor that affected her receiving optimal care. Due to deconditioning and worsening hemothorax, the patient required emergent surgical management. Despite increased morbidity and mortality from conventional surgery, the patient tolerated VAT and demonstrated significant improvement. VATS is a safe, effective option for surgical management of posttraumatic hemothorax in elderly patients age ≥80. VATS is superior to standard thoracotomy in terms of both morbidity and mortality, therefore, age alone should not be a contraindication to operative intervention.

References:

  1. Jaklitsch MT, DeCamp MM Jr, Liptay MJ, Harpole DH Jr, Swanson SJ, Mentzer SJ, Sugarbaker DJ. Video-assisted thoracic surgery in the elderly. A review of 307 cases. Chest. 1996 Sep;110(3):751-8. doi: 10.1378/chest.110.3.751. PMID: 8797422.
  2. Lin HL, Huang WY, Yang C, Chou SM, Chiang HI, Kuo LC, Lin TY, Chou YP. How early should VATS be performed for retained haemothorax in blunt chest trauma? Injury. 2014 Sep;45(9):1359-64. doi: 10.1016/j.injury.2014.05.036. Epub 2014 Jun 5. PMID: 24985468.
  3. Schweigert M, Beron M, Dubecz A, Stadlhuber R, Stein H. Video-assisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly. Thorac Cardiovasc Surg. 2012 Oct;60(7):474-9. doi: 10.1055/s-0031-1298069. Epub 2012 Jan 20. PMID: 22266929.
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