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El-Akkawi AI, Media AS, Eykens Hjørnet N, Nielsen DV, Modrau IS. Timing of Chest Tube Removal Following Adult Cardiac Surgery: A Cluster Randomized Controlled Trial. SCAND CARDIOVASC J 2024; 58:2294681. [PMID: 38112193 DOI: 10.1080/14017431.2023.2294681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES Early chest tube removal following cardiac surgery may be associated with an increased risk of pleural or pericardial effusions following cardiac surgery. This study compares the effects of two fast-track chest tube removal protocols regarding the risk of pleural or pericardial effusions, requirement of opioids, respiratory function, and postoperative complications. DESIGN Prospective non-blinded cluster-randomized study with alternating chest tube removal protocol in adult patients undergoing elective cardiac surgery. Monthly changing allocation to scheduled chest tube removal on the day of surgery (Day 0) versus removal on the 1st postoperative day (Day 1) provided no air leakage and output < 200 mL within the last four hours. RESULTS A total of 527 patients were included in the study from September 1st 2020 until October 29th 2021 and randomly allocated to chest tube removal at day 0 (n = 255), and day 1 (n = 272). More than every fourth patient required drainage for pleural effusion with no significant difference between the groups. Earlier removal of chest tubes did not reduce requirement of analgesics, improve early respiratory function, or reduce postoperative complications. The study was halted for futility after halfway interim analysis showed insufficient promise of any treatment benefit. CONCLUSION Fast-track protocols with chest tube removal within the first 24 h after cardiac surgery may be associated a high rate of pleural effusions.
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Affiliation(s)
- Ali Imad El-Akkawi
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Ara Shwan Media
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Eykens Hjørnet
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Dorthe Viemose Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ivy Susanne Modrau
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Takamochi K, Haruki T, Oh S, Endo M, Funai K, Kitamura Y, Tsuboi M, Tsukioka T, Suzuki H, Ito H, Okumura N, Ueno T, Ikeda N, Iwata H, Okada M, Ichikawa T, Okamoto T, Nojiri S, Suzuki K. Early chest tube removal regardless of drainage volume after anatomic pulmonary resection: A multicenter, randomized, controlled trial. J Thorac Cardiovasc Surg 2024; 168:401-410.e1. [PMID: 38348845 DOI: 10.1016/j.jtcvs.2023.10.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 07/15/2024]
Abstract
OBJECTIVES This study aimed to evaluate the safety and feasibility of early chest tube removal after anatomic pulmonary resection, regardless of the drainage volume. METHODS We conducted a multicenter, randomized, controlled, noninferiority trial. Patients with greater than 300 mL drainage volume during postoperative day 1 were randomly assigned to group A (tube removed on postoperative day 2) and group B (tube retained until drainage volume ≤300 mL/24 hours). The primary end point was the frequency of respiratory-related adverse events (grade 2 or higher based on the Clavien-Dindo classification) within 30 days postoperatively. RESULTS Between April 2019 and October 2021, 175 patients were assigned to group A (N = 88) or group B (N = 87). One patient in group B who experienced chylothorax was excluded from the study. Respiratory-related adverse events were observed in 10 patients (11.4%) in group A and 12 patients (14.0%) in group B (P = .008). The frequencies of thoracentesis or chest tube reinsertion were not significantly different (8.0% and 9.3% in groups A and B, respectively, P = .752). Additionally, the duration of chest tube placement was significantly shorter in group A than in group B (median, 2 vs 3 days; P < .001). No significant difference between groups A and B was found in postoperative hospital stay (median, 6 vs 7 days, P = .231). CONCLUSIONS Early chest tube removal, regardless of drainage volume, was safe and feasible in patients who underwent anatomic pulmonary resection.
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Affiliation(s)
- Kazuya Takamochi
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Tomohiro Haruki
- Division of General Thoracic Surgery, Department of Surgery, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Shiaki Oh
- General Thoracic Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Makoto Endo
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Kazuhito Funai
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | | | - Masahiro Tsuboi
- Department of Thoracic Surgery and Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takuma Tsukioka
- Department of Thoracic Surgery, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Hiroyuki Suzuki
- Department of Chest Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hiroyuki Ito
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Norihito Okumura
- Department of Thoracic Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tsuyoshi Ueno
- Department of Thoracic Surgery, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Norihito Ikeda
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hisashi Iwata
- Department of General Thoracic Surgery, Gifu University Hospital, Gifu, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | | | - Tatsuro Okamoto
- Department of Thoracic Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Shuko Nojiri
- Juntendo Clinical Research and Trial Center, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Gioutsos K, Ehrenreich L, Azenha LF, Quapp CS, Kocher GJ, Lutz JA, Peischl S, Dorn P. Randomized Controlled Trial of Thresholds for Drain Removal After Anatomic Lung Resection. Ann Thorac Surg 2024; 117:1103-1109. [PMID: 37734641 DOI: 10.1016/j.athoracsur.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/10/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND The criteria for chest drain removal after lung resections remain vague and rely on personal experience instead of evidence. Because pleural fluid resorption is proportional to body weight, a weight-related approach seems reasonable. We examined the feasibility of a weight-adjusted fluid output threshold concerning postoperative respiratory complications and the occurrence of symptomatic pleural effusion after chest drain removal. Our secondary objectives were the hospital length of stay and pain levels before and after chest drain removal. METHODS This was a single-center randomized controlled trial including 337 patients planned for open or thoracoscopic anatomical lung resections. Patients were randomly assigned postoperatively into 2 groups. The chest drain was removed in the study group according to a fluid output threshold calculated by the 5 mL × body weight (in kg)/24 hours formula. In the control group, our previous traditional fluid threshold of 200 mL/24 hours was applied. RESULTS No differences were evident regarding the occurrence of pleural effusion and dyspnea at discharge and 30 days postoperatively. In the logistic regression analysis, the surgical modality was a risk factor for other complications, and age was the only variable influencing postoperative dyspnea. Time to chest drain removal was identical in both groups, and time to discharge was shorter after open surgery in the test group. CONCLUSIONS No increased postoperative complications occurred with this weight-based formula, and a trend toward earlier discharge after open surgery was observed in the test group.
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Affiliation(s)
- Konstantinos Gioutsos
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lasse Ehrenreich
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Filipe Azenha
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christopher Siegbert Quapp
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregor Jan Kocher
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jon Andri Lutz
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Peischl
- Interfaculty Bioinformatics Unit and SIB Swiss Institute of Bioinformatics, University of Bern, Bern, Switzerland
| | - Patrick Dorn
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Zhu J, Xia X, Li R, Song W, Zhang Z, Lu H, Li Z, Guo Q. Efficacy and safety of early chest tube removal after selective pulmonary resection with high-output drainage: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e33344. [PMID: 36961179 PMCID: PMC10036022 DOI: 10.1097/md.0000000000033344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/01/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND There is controversy over the drainage threshold for removal of chest tubes in the absence of significant air leakage after selective pulmonary resection. METHODS A comprehensive search of online databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, Ovid, Elsevier, Ebsco, and Wiley) and clinical trial registries (WHO-ICTRP and ClinicalTrials.gov) was performed to investigate the efficacy and safety of early chest tube removal with high-output drainage. Primary outcome (postoperative hospital day) and secondary outcomes (30-day complications, rate of thoracentesis, and chest tube placement) were extracted and synthesized. Subgroup analysis, meta-regression, and sensitivity analysis were used to explore the potential heterogeneity. Study quality was assessed with the Newcastle-Ottawa Scale, and evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment by the online GRADEpro Guideline Development Tool. RESULTS Six cohort studies with a total of 1262 patients were included in the final analysis. The postoperative hospital stay in the high-output group was significantly shorter than in the conventional treatment group (weighted mean difference: -1.34 [-2.34 to -0.34] day, P = .009). While there was no significant difference between 2 groups in 30-day complications (relative ratio [RR]: 0.92 [0.77-1.11], P = .38), the rate of thoracentesis (RR: 1.93 [0.63-5.88], P = .25) and the rate of chest tube placement (RR: 1.00 [0.37-2.70], P = .99). According to the sensitivity analysis, the relative impacts of the 2 groups had already stabilized. Subgroup analysis revealed that postoperative hospital stay was modified by Newcastle-Ottawa Scale score. The online GRADEpro Guideline Development Tool presented very low quality of evidence for the available data. CONCLUSIONS This meta-analysis revealed that it is feasible and safe to remove a chest tube with high-output drainage after pulmonary resection for selected patients.
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Affiliation(s)
- Junwei Zhu
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Xueyang Xia
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Rongyao Li
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Weikang Song
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Zhiqiang Zhang
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Huawei Lu
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Zhiwei Li
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
| | - Qingwei Guo
- Department of Thoracic Surgery, Zhoukou Central Hospital, Zhoukou, China
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Brat K, Homolka P, Merta Z, Chobola M, Heroutova M, Bratova M, Mitas L, Chovanec Z, Horvath T, Benej M, Ivicic J, Svoboda M, Sramek V, Olson LJ, Cundrle I. Prediction of Postoperative Complications: Ventilatory Efficiency and Rest End-tidal Carbon Dioxide. Ann Thorac Surg 2022; 115:1305-1311. [PMID: 35074321 DOI: 10.1016/j.athoracsur.2021.11.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/10/2021] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing parameters including ventilatory efficiency (VE/VCO2 slope) are used for risk assessment of lung resection candidates. However, many patients are unable or unwilling to undergo exercise. VE/VCO2 slope is closely related to the partial pressure of end-tidal carbon dioxide (PETCO2). We hypothesized PETCO2 at rest predicts postoperative pulmonary complications. METHODS Consecutive lung resection candidates were included in this prospective multicenter study. Postoperative respiratory complications were assessed from the first 30 postoperative days or from the hospital stay. Student t test or Mann-Whitney U test was used for comparison. Multivariate stepwise logistic regression analysis was used to analyze association with the development of postoperative pulmonary complications. The De Long test was used to compare area under the curve (AUC). Data are summarized as median (interquartile range). RESULTS Three hundred fifty-three patients were analyzed, of which 59 (17%) developed postoperative pulmonary complications. PETCO2 at rest was significantly lower (27 [24-30] vs 29 [26-32] mm Hg; P < .01) and VE/VCO2 slope during exercise significantly higher (35 [30-40] vs 29 [25-33]; P < .01) in patients who developed postoperative pulmonary complications. Both rest PETCO2 with odds ratio 0.90 (95% confidence interval [CI] 0.83-0.97); P = .01 and VE/VCO2 slope with odds ratio 1.10 (95% CI 1.05-1.16); P < .01 were independently associated with postoperative pulmonary complications by multivariate stepwise logistic regression analysis. There was no significant difference between AUC of both models (rest PETCO2: AUC = 0.79 (95% CI 0.74-0.85); VE/VCO2 slope: AUC = 0.81 (95% CI 0.75-0.86); P = .48). CONCLUSIONS PETCO2 at rest has similar prognostic utility as VE/VCO2 slope, suggesting rest PETCO2 may be used for postoperative pulmonary complications prediction in lung resection candidates.
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A simple size-tailored algorithm for the removal of chest drain following minimally invasive lobectomy: a prospective randomized study. Surg Endosc 2021; 36:5275-5281. [PMID: 34846593 PMCID: PMC9160124 DOI: 10.1007/s00464-021-08905-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/21/2021] [Indexed: 11/26/2022]
Abstract
Background The pleural space can resorb 0.11–0.36 ml/kg of body weight/hour (h) per hemithorax. There are only a limited number of studies on thresholds for chest drain removal (CDR) and all are based on arbitrary amounts, for example, 300 ml/day. We studied an individualized size-based threshold for CDR–specifically 5 ml/kg, a simple, easily applicable measure. Methods This is a single-center prospective randomized trial enrolling 80 patients undergoing VATS lobectomy. There were two groups: an experimental (E) group, in which once the daily output went down to 5 ml/kg the chest drain was removed and a control (C) group, with chest drain removal as per our current practice of less than 250 ml/day. Results The groups did not differ in pre- and peri- and postoperative characteristics, except for chest drain duration (mean, SD 2.02 ± 0.97 vs. 3.25 ± 1.39 days, p < 0.001) and length of hospital stay (median, IQR 4.5; 3 vs. 6; 2.75 days, p = 0.008) in favor of E group. The re-intervention rate was the same in both groups (once in each group). Conclusion The new threshold for chest drain removal following thoracoscopic lobectomy of 5 ml/kg/d leads to both shorter chest drainage and hospital stay without apparent increase in morbidity. (Clinical registration number: DRKS00014252).
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Wong T, Gold J, Houser R, Herschman Y, Jani R, Goldstein I. Ventriculopleural shunt: Review of literature and novel ways to improve ventriculopleural shunt tolerance. J Neurol Sci 2021; 428:117564. [PMID: 34242833 DOI: 10.1016/j.jns.2021.117564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 05/21/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
Cerebrospinal fluid (CSF) diversion is among the most commonneurosurgical procedures that are performed worldwide. It is estimated thatapproximately 30,000 ventriculostomies are performed annually in the United States.Ventriculoperitoneal (VP) shunt malfunction rate within the first year of initialimplantation has been reported to be as high as 11-25%. In patients with abdominaladhesions, infections or multiple failed VP shunts, another bodily compartment shouldbe utilized as a substitute for the peritoneal cavity for distal shunt catheter placement.Ventriculopleural (VPL) shunting for hydrocephalus was first introduced by Heile in1914. Since the inception of this idea, VPL shunts have been utilized in select patientswith varying degrees of success. There have been a number of case reports andseries documenting unique complications with VPL shunting, with pleural effusion andpneumothorax being the most common complications. In our review article, we soughtto review the development of VPL shunting, pleuropulmonary physiology, insertiontechniques for VPL shunt, complications associated with VPL shunts, and uniquestrategies to improve VPL shunt tolerance.
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Affiliation(s)
- Timothy Wong
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Justin Gold
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America.
| | - Ryan Houser
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Yehuda Herschman
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Raja Jani
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Ira Goldstein
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
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Brookes JDL, Williams M, Mathew M, Yan T, Bannon P. Pleural effusion post coronary artery bypass surgery: associations and complications. J Thorac Dis 2021; 13:1083-1089. [PMID: 33717581 PMCID: PMC7947477 DOI: 10.21037/jtd-20-2082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background One of the most frequent complications of coronary artery bypass grafting (CABG) is pleural effusion. Limited previous studies have found post-CABG pleural effusion to be associated with increased length-of-stay and greater morbidity post-CABG. Despite this the associations of this common complication are poorly described. This study sought to identify modifiable risk factors for effusion post-CABG. Methods A retrospective cohort study of prospectively collected data assessed patients who underwent CABG over two-years. Data was collected for risk factors and sequelae related to pleural effusion requiring drainage. Results A total of 409 patients were included. Average age was 64.9±10.2 years, 330 (80.7%) were male. 59 (14.4%) patients underwent drainage of pleural effusion post-CABG. Effusions were drained on average 9.9±8.4 days post-CABG. Earlier removal of drain tubes and removal near time of extubation were associated with development of pleural effusion. Post-CABG pleural effusion was associated with post-operative renal impairment (P<0.01) and pericardial effusion (P<0.01). Patients with pleural effusion were more likely to require readmission to ICU (P<0.01), reintubation (P=0.03) and readmission to hospital (P=0.03). Conclusions Pleural effusion is a common complication of cardiac surgery and is associated with significant morbidity and resource utilization. This study identifies several associated complications that should be considered in the presence of pleural effusion. Modifiable associated factors in the management of drains that may contribute to accumulation of pleural effusion include: early removal of chest drains, higher outputs and removal during or close to mechanical ventilation. Further research is required to assess how adjusting these modifiable factors can decrease rates of effusion post-operatively.
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Affiliation(s)
- John D L Brookes
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Michael Williams
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Manish Mathew
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Tristan Yan
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Sydney Medical School, The University of Sydney, New South Wales, Australia.,Professor of Cardiovascular and Thoracic Surgery, Macquarie University, New South Wales, Australia.,Clinical Professor of Surgery, Faculty of Medicine, The University of Sydney, New South Wales, Australia.,The Baird Institute, Newtown, New South Wales, Australia
| | - Paul Bannon
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Sydney Medical School, The University of Sydney, New South Wales, Australia.,The Baird Institute, Newtown, New South Wales, Australia.,Bosch Professor of Surgery, Faculty of Medicine, The University of Sydney, New South Wales, Australia
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Beattie G, Cohan CM, Chomsky-Higgins K, Tang A, Senekjian L, Victorino GP. Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis. Injury 2020; 51:2493-2499. [PMID: 32747140 DOI: 10.1016/j.injury.2020.07.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/24/2020] [Accepted: 07/25/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Following placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective. METHODS We performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. RESULTS Decision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations. CONCLUSION In trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.
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Affiliation(s)
- Genna Beattie
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Caitlin M Cohan
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Kathryn Chomsky-Higgins
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Lara Senekjian
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
| | - Gregory P Victorino
- Department of Surgery, University of California San Francisco, East Bay, 1411 E 31st Oakland, CA 94602 United States.
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10
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Becker JC, Zakaluzny SA, Keller BA, Galante JM, Utter GH. Clamping trials prior to thoracostomy tube removal and the need for subsequent invasive pleural drainage. Am J Surg 2020; 220:476-481. [DOI: 10.1016/j.amjsurg.2020.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 12/27/2019] [Accepted: 01/03/2020] [Indexed: 11/24/2022]
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Tang MB, Li JL, Tian SY, Gao XL, Liu W. Predictive factors for pleural drainage volume after uniportal video-assisted thoracic surgery lobectomy for non-small cell lung cancer: a single-institution retrospective study. World J Surg Oncol 2020; 18:162. [PMID: 32641064 PMCID: PMC7346611 DOI: 10.1186/s12957-020-01941-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/01/2020] [Indexed: 12/25/2022] Open
Abstract
Objective To identify the predictive factors associated with pleural drainage volume (PDV) after uniportal video-assisted thoracic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC). Methods A total of 440 consecutive NSCLC patients who underwent uniportal VATS lobectomy were enrolled in this study between November 2016 and July 2019. Thirty-four parameters, including patients’ clinicopathological characteristics and other potential predictors were collected. Daily drainage volume was summed up as PDV. Univariate analysis and multivariate regression models were fitted to identify independent predictive factors for PDV. Results The median PDV was 840 ml during the median drainage duration of 4 days. A strong correlation was observed between PDV and drainage duration (correlation coefficient = 0.936). On univariate analysis, age, forced expiratory volume in 1 s % predicted (FEV1%), left ventricular ejection fraction (LVEF), operation time, serum total protein (TP), and body mass index (BMI) showed a significant correlation with PDV (P value, < 0.001, < 0.001, 0.003, 0.008, 0.028, and 0.045, respectively). Patients with smoking history (P = 0.030) or who underwent lower lobectomy (P = 0.015) showed significantly increased PDV than never smokers or those who underwent upper or middle lobectomy, respectively. On multivariate regression analysis, older age (P< 0.001), lower FEV1% (P< 0.001), lower LVEF (P = 0.011), lower TP (P = 0.013), and lower lobectomy (P = 0.016) were independent predictors of increased PDV. Conclusions Predictive factors of PDV can be identified. Based on these predictors, patients can be treated with tailored individualized safe chest tube management.
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Affiliation(s)
- Ming-Bo Tang
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China
| | - Jia-Lin Li
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China
| | - Su-Yan Tian
- Department of Division of Clinical Research, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Xin-Liang Gao
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China
| | - Wei Liu
- Department of Thoracic Surgery, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, Jilin, 130021, China.
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Bertrandt RA, Saudek DM, Scott JP, Madrzak M, Miranda MB, Ghanayem NS, Woods RK. Chest tube removal algorithm is associated with decreased chest tube duration in pediatric cardiac surgical patients. J Thorac Cardiovasc Surg 2019; 158:1209-1217. [PMID: 31147165 DOI: 10.1016/j.jtcvs.2019.03.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/15/2019] [Accepted: 03/30/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Management of chest tubes in adult and pediatric patients is highly variable. There are no published guidelines for pediatric cardiac surgical patients. Our center undertook a quality improvement project aimed at reducing chest tube duration and length of stay in postsurgical pediatric cardiac patients. METHODS A work group identified 2 opportunities for reducing chest tube duration: standardizing removal criteria and increasing frequency of assessment for removal. An algorithm was created, and chest tube assessments were increased to twice daily. All postsurgical cardiac patients were managed according to the algorithm. Outcome measure reporting was limited to patients age 1 month to 18 years with a biventricular surgical procedure. Outcome measures included chest tube duration, cardiac intensive care unit and hospital length of stay, and cost of hospitalization. Process measure was documentation of chest tube assessments. The balancing measure was chest tube reinsertions. RESULTS Between April 2016 and July 2018, 126 patients aged 1 month to 18 years underwent a biventricular surgical procedure. Mean chest tube duration decreased from 61 to 47 hours. Cardiac intensive care unit length of stay decreased from 141 hours to 89 hours, hospital length of stay decreased from 266 to 156 hours, and average hospitalization cost decreased from $75,881 to $48,118. There was no increase in chest tube reinsertions. CONCLUSIONS Implementation of a chest tube removal algorithm for pediatric cardiac surgery patients resulted in decreased chest tube duration and was associated with decreased length of stay and costs without an increase in reinsertions. More significant impact may be attainable with more aggressive approach to removal.
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Affiliation(s)
- Rebecca A Bertrandt
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
| | - David M Saudek
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - John P Scott
- Division of Anesthesiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Michael Madrzak
- Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Mary Beth Miranda
- Department of Quality and Patient Safety, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Ronald K Woods
- Division of Cardiothoracic Surgery, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
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Abstract
Limited evidence exists to guide chest tube management following cardiac surgery in children. We assessed chest tube practice variation by surveying paediatric heart centres to prepare for a multi-site quality improvement project. We summarised management strategies highlighting variability in criteria for chest tube removal between and within centres. This lack of standardisation provides an opportunity for quality improvement.
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Asti E, Sironi A, Bonitta G, Bernardi D, Bonavina L. Transhiatal Chest Drainage After Hybrid Ivor Lewis Esophagectomy: Proof of Concept Study. J Laparoendosc Adv Surg Tech A 2017; 28:429-433. [PMID: 29237133 DOI: 10.1089/lap.2017.0580] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Intercostal pleural drainage is standard practice after transthoracic esophagectomy but has some drawbacks. We hypothesized that a transhiatal pleural drain introduced through the subxyphoid port site incision at laparoscopy can be as effective as the intercostal drainage and may enhance patient recovery. PATIENTS AND METHODS A proof of concept study was designed to assess a new method of pleural drainage in patients undergoing hybrid Ivor Lewis esophagectomy (laparoscopy and right thoracotomy). The main study aims were safety and efficacy of transhiatal pleural drainage with a 15 Fr Blake tube connected to a portable vacuum system. Pre- and postoperative data, mean duration, and total and daily output of drainage were recorded in an electronic database. Postoperative complications were scored according to the Dindo-Clavien classification. RESULTS Between June 2015 and December 2016, 50 of 63 consecutive patients met the criteria for inclusion in the study. No conversions from the portable vacuum system to underwater seal and suction occurred. There was no mortality. The overall morbidity rate was 40%. Two patients (4%) required reoperation for hemothorax and chylothorax, respectively. Percutaneous catheter drainage for residual pneumothorax was necessary in 2 patients (4%) on postoperative day 2. The mean duration of drainage was 7 days (interquartile range [IQR] = 2), and the total volume of drain output was 1580 mL (IQR = 880). No pleural effusion on chest X-ray was detected at the 3-month follow-up visit. CONCLUSIONS Transhiatal pleural drainage is safe and effective after hybrid Ivor Lewis esophagectomy and could replace the intercostal drain in selected patients.
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Affiliation(s)
- Emanuele Asti
- Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan Medical School , Milano, Italy
| | - Andrea Sironi
- Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan Medical School , Milano, Italy
| | - Gianluca Bonitta
- Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan Medical School , Milano, Italy
| | - Daniele Bernardi
- Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan Medical School , Milano, Italy
| | - Luigi Bonavina
- Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan Medical School , Milano, Italy
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Yan S, Wang X, Wang Y, Lv C, Wang Y, Wang J, Yang Y, Wu N. Intermittent chest tube clamping may shorten chest tube drainage and postoperative hospital stay after lung cancer surgery: a propensity score matching analysis. J Thorac Dis 2017; 9:5061-5067. [PMID: 29312711 DOI: 10.21037/jtd.2017.11.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Postoperative pleural drainage markedly influences the length of hospital stay and the financial costs of medical care. The safety of chest tube clamping before removal has been documented. This study aims to determine if intermittent chest tube clamping shortens the duration of chest tube drainage and hospital stay after lung cancer surgery. Methods We retrospectively analyzed 285 consecutive patients with operable lung cancer treated using lobectomy and systematic mediastinal lymphadenectomy. The chest tube management protocol in our institution was changed in January 2014, and thus, 222 patients (clamping group) were managed with intermittent chest tube clamping, while 63 patients (control group) were managed with a traditional protocol. Propensity score matching at a 1:1 ratio was applied to balance variables potentially affecting the duration of chest tube drainage. Analyses were performed to compare drainage duration and postoperative hospital stay between the two groups in the matched cohort. Multivariate logistic regression analyses were performed to predict the factors associated with chest tube drainage duration. Results The rates of thoracocentesis after chest tube removal were similar between the clamping and control groups in the whole cohort (0.5% vs. 1.6%, P=0.386). The rates of pyrexia were also comparable in the two groups (2.3% vs. 3.2%, P=0.685). After propensity score matching, 61 cases remained in each group. Both chest tube drainage duration (3.9 vs. 4.8 days, P=0.001) and postoperative stay (5.7 vs. 6.4 days, P=0.025) were significantly shorter in the clamping group than in the control group. Factors significantly associated with shorter chest tube drainage duration were female sex, chest tube clamping, left lobectomy, and video-assisted thoracoscopic surgery (VATS) (P<0.05). Conclusions Intermittent postoperative chest tube clamping may decrease the duration of chest tube drainage and postoperative hospital stay while maintaining patient safety.
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Affiliation(s)
- Shi Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xing Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yaqi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Chao Lv
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yuzhao Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jia Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yue Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Nan Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
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Ring LM, Watson A. Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline. J Pediatr Health Care 2017; 31:671-683. [PMID: 28688940 DOI: 10.1016/j.pedhc.2017.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/13/2017] [Accepted: 05/15/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Thoracostomy tubes are placed following cardiothoracic surgery for the repair or palliation of congenital heart defects. The aim of this project was to develop and implement a clinical practice guideline for the provision of optimal analgesia during removal of thoracostomy tubes in pediatric postoperative cardiothoracic surgery patients. METHODS Methods used include a nonexperimental design utilizing chart audits to determine baseline documentation as well as procedure note evaluation to determine both baseline documentation and compliance with the new guideline. A convenience sample of unit-based nurses completed a knowledge test and a post-implementation survey. RESULTS There was a significant increase in nursing knowledge related to the clinical practice guideline education and implementation. Documentation compliance was observed. Nursing satisfaction and feasibility of the new guideline was demonstrated. DISCUSSION This project was successful in increasing nursing knowledge of available resources for optimal procedural pain management in pediatric patients requiring thoracostomy tube removal on one in-patient acute care unit.
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Mahadeo KM, McArthur J, Adams RH, Radhi M, Angelo J, Jeyapalan A, Nicol K, Su L, Rabi H, Auletta JJ, Pai V, Duncan CN, Tamburro R, Dvorak CC, Bajwa RPS. Consensus Report by the Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplant Consortium Joint Working Committees on Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents: Part 2-Focus on Ascites, Fluid and Electrolytes, Renal, and Transfusion Issues. Biol Blood Marrow Transplant 2017; 23:2023-2033. [PMID: 28823876 DOI: 10.1016/j.bbmt.2017.08.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/10/2017] [Indexed: 01/19/2023]
Abstract
Even though hepatic veno-occlusive disease (VOD) is a potentially fatal complication of hematopoietic cell transplantation (HCT), there is paucity of research on the management of associated multiorgan dysfunction. To help provide standardized care for the management of these patients, the HCT Subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators and the Supportive Care Committee of the Pediatric Blood and Marrow Transplant Consortium, collaborated to develop evidence-based consensus guidelines. After conducting an extensive literature search, in part 2 of this series we discuss the management of fluids and electrolytes, renal dysfunction; ascites, pleural effusion, and transfusion and coagulopathy issues in patients with VOD. We consider the available evidence using the GRADE criteria.
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Affiliation(s)
- Kris M Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy, MD Anderson Children's Cancer Hospital Houston, The University of Texas, Houston, Texas
| | - Jennifer McArthur
- Department of Pediatric Critical Care Medicine, St Jude Children's Research Hospital Memphis, Memphis, Tennessee
| | - Roberta H Adams
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona; Hematology/Oncology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Mohamed Radhi
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, Missouri
| | - Joseph Angelo
- Division of Nephrology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Asumthia Jeyapalan
- Division of Pediatric Critical Care Medicine, University of Miami- Miller School of Medicine, Miami, Florida
| | - Kathleen Nicol
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Leon Su
- Department of Pathology and Laboratory Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Hanna Rabi
- Division of Pediatric Hematology Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jeffery J Auletta
- Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio; Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Vinita Pai
- College of Pharmacy and Pharmacy Department, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Christine N Duncan
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert Tamburro
- Division of Pediatric Critical Care Medicine, Pennsylvania University, Penn State Hershey Children's Hospital, Hershey, PA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Rajinder P S Bajwa
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio.
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Hung GC, Gaunt MC, Rubin JE, Starrak GS, Sakals SA. Quantification and characterization of pleural fluid in healthy dogs with thoracostomy tubes. Am J Vet Res 2016; 77:1387-1391. [DOI: 10.2460/ajvr.77.12.1387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Yan S, Wang X, Lv C, Phan K, Wang Y, Wang J, Yang Y, Wu N. Mediastinal micro-vessels clipping during lymph node dissection may contribute to reduce postoperative pleural drainage. J Thorac Dis 2016; 8:415-21. [PMID: 27076936 DOI: 10.21037/jtd.2016.02.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postoperative pleural drainage markedly influences the length of postoperative stay and financial costs of medical care. The aim of this study is to retrospectively investigate potentially predisposing factors related to pleural drainage after curative thoracic surgery and to explore the impact of mediastinal micro-vessels clipping on pleural drainage control after lymph node dissection. METHODS From February 2012 to November 2013, 322 consecutive cases of operable non-small cell lung cancers (NSCLC) undergoing lobectomy and mediastinal lymph node dissection with or without application of clipping were collected. Total and daily postoperative pleural drainage were recorded. Propensity score matching (1:2) was applied to balance variables potentially impacting pleural drainage between group clip and group control. Analyses were performed to compare drainage volume, duration of chest tube and postoperative hospital stay between the two groups. Variables linked with pleural drainage in whole cohort were assessed using multivariable logistic regression analysis. RESULTS Propensity score matching resulted in 197 patients (matched cohort). Baseline patient characteristics were matched between two groups. Group clip showed less cumulative drainage volume (P=0.020), shorter duration of chest tube (P=0.031) and postoperative hospital stay (P=0.022) compared with group control. Risk factors significantly associated with high-output drainage in multivariable logistic regression analysis were being male, age >60 years, bilobectomy/sleeve lobectomy, pleural adhesion, the application of clip applier, duration of operation ≥220 minutes and chylothorax (P<0.05). CONCLUSIONS This study suggests that mediastinal micro-vessels clipping during lymph node dissection may reduce postoperative pleural drainage and thus shorten hospital stay.
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Affiliation(s)
- Shi Yan
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Xing Wang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Chao Lv
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Kevin Phan
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Yuzhao Wang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Jia Wang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Yue Yang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Nan Wu
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
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French DG, Dilena M, LaPlante S, Shamji F, Sundaresan S, Villeneuve J, Seely A, Maziak D, Gilbert S. Optimizing postoperative care protocols in thoracic surgery: best evidence and new technology. J Thorac Dis 2016; 8:S3-S11. [PMID: 26941968 DOI: 10.3978/j.issn.2072-1439.2015.10.67] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Postoperative clinical pathways have been shown to improve postoperative care and decrease length of stay in hospital. In thoracic surgery there is a need to develop chest tube management pathways. This paper considers four aspects of chest tube management: (I) appraising the role of chest X-rays in the management of lung resection patients with chest drains; (II) selecting of a fluid output threshold below which chest tubes can be removed safely; (III) deciding whether suction should be applied to chest tubes; (IV) and selecting the safest method for chest tube removal. There is evidence that routine use of chest X-rays does not influence the management of chest tubes. There is a lack of consensus on the highest fluid output threshold below which chest tubes can be safely removed. The optimal use of negative intra-pleural pressure has not yet been established despite multiple randomized controlled trials and meta-analyses. When attempting to improve efficiency in the management of chest tubes, evidence in support of drain removal without a trial of water seal should be considered. Inconsistencies in the interpretation of air leaks and in chest tube management are likely contributors to the conflicting results found in the literature. New digital pleural drainage systems, which provide a more objective air leak assessment and can record air leak trend over time, will likely contribute to the development of new evidence-based guidelines. Technology should be combined with continued efforts to standardize care, create clinical pathways, and analyze their impact on postoperative outcomes.
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Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Michael Dilena
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Simon LaPlante
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Farid Shamji
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Sudhir Sundaresan
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - James Villeneuve
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Andrew Seely
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Donna Maziak
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
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Huang PM, Kuo SW, Chen JS, Lee JM. Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience. Ann Thorac Surg 2016; 101:1921-7. [PMID: 26897323 DOI: 10.1016/j.athoracsur.2015.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 10/05/2015] [Accepted: 11/09/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND The objective was to analyze the outcomes of thoracoscopic mesh repair for hepatic hydrothorax (HH) at our institution during the past 10 years. METHODS A total of 63 patients with refractory HH who underwent thoracoscopic mesh onlay reinforcement to repair diaphragmatic defects from January 2005 to December 2014 were included in the study. Mesh covering alone was used in 47 patients and mesh with suturing was used in 16 patients. Patient demographics, Child-Pugh class, and model for end-stage liver disease (MELD) score were evaluated to predict morbidity and mortality. RESULTS Of the patients (mean age, 60.4 ± 15 years; 31 men and 32 women), 14.3% had concomitant underlying diseases of renal insufficiency, 34.9% had diabetes mellitus, and 4.8% had pneumonia. Diaphragmatic blebs were the most common diaphragmatic defects (29 of 63 [46%]). After a median 20.5 months of follow-up examinations, 4 patients experienced recurrence. The 1-month mortality rate was 9.5% (6 of 63 patients). On multivariable analysis, underlying impaired renal function (p = 0.039) and MELD scores (p = 0.048) were associated with increased 3-month mortality in 16 patients. Contrary to the rising Child-Pugh score (p = 0.058), rising MELD scores represented an increase in kidney or liver failure and mortality. The main causes of 3-month mortality were septic shock (n = 6), acute renal insufficiency (n = 4), gastrointestinal bleeding (n = 4), hepatic encephalopathy (n = 1), and ischemic bowel (n = 1). CONCLUSIONS Thoracoscopic mesh repair for refractory HH improves symptoms and lowers the recurrence rate.
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Affiliation(s)
- Pei-Ming Huang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Shuenn-Wen Kuo
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Shing Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jang-Ming Lee
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Yao F, Wang J, Yao J, Hang F, Cao S, Qian J, Xu L. Early Chest Tube Removal After Thoracoscopic Esophagectomy with High Output. J Laparoendosc Adv Surg Tech A 2016; 26:17-22. [PMID: 26618398 DOI: 10.1089/lap.2015.0454] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Fei Yao
- Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jian Wang
- Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ju Yao
- Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Fangrong Hang
- Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shiqi Cao
- Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Junling Qian
- Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lei Xu
- Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Mesa-Guzman M, Periklis P, Niwaz Z, Socci L, Raubenheimer H, Adams B, Gurung L, Uzzaman M, Lim E. Determining optimal fluid and air leak cut off values for chest drain management in general thoracic surgery. J Thorac Dis 2015; 7:2053-7. [PMID: 26716045 DOI: 10.3978/j.issn.2072-1439.2015.11.42] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Chest drain duration is one of the most important influencing aspects of hospital stay but the management is perhaps one of the most variable aspects of thoracic surgical care. The aim of our study is to report outcomes associated with increasing fluid and air leak criteria of protocol based management. METHODS A 6-year retrospective analysis of protocolised chest drain management starting in 2007 with a fluid criteria of 3 mL/kg increasing to 7 mL/kg in 2011 to no fluid criteria in 2012, and an air leak criteria of 24 hours without leak till 2012 when digital air leak monitoring was introduced with a criteria of <20 mL/min of air leak for more than 6 hours. Patient data were obtained from electronic hospital records and digital chest films were reviewed to determine the duration of chest tube drainage and post-drain removal complications. RESULTS From 2009 to 2012, 626 consecutive patients underwent thoracic surgery procedures under a single consultant. A total of 160 did not require a chest drain and data was missing in 22, leaving 444 for analysis. The mean age [standard deviation (SD)] was 57±19 years and 272 (61%) were men. There were no differences in the incidence of pneumothoraces (P=0.191), effusion (P=0.344) or re-interventions (P=0.431) for drain re-insertions as progressively permissive criteria were applied. The median drain duration dropped from 1-3 days (P<0.001) and accordingly hospital stay reduced from 4-6 days (P<0.001). CONCLUSIONS Our results show that chest drains can be safely removed without fluid criteria and air leak of less than 20 mL/min with median drain duration of 1 day, associated with a reduced length of hospital stay.
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Affiliation(s)
- Miguel Mesa-Guzman
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Perikleous Periklis
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Zakiyah Niwaz
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Laura Socci
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Hilgardt Raubenheimer
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Ben Adams
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Lokesh Gurung
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Mohsin Uzzaman
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
| | - Eric Lim
- 1 Department of Thoracic Surgery, 2 Department Quality and Safety, Royal Brompton Hospital, London, UK
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Holbek BL, Horsleben Petersen R, Kehlet H, Hansen HJ. Fast-track video-assisted thoracoscopic surgery: future challenges. SCAND CARDIOVASC J 2015; 50:78-82. [DOI: 10.3109/14017431.2015.1114665] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Weber GF. Immune targeting of the pleural space by intercostal approach. BMC Pulm Med 2015; 15:14. [PMID: 25880308 PMCID: PMC4336760 DOI: 10.1186/s12890-015-0010-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 02/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infectious diseases of the airways are a major health care problem world wide. New treatment strategies focus on employing the body's immune system to enhance its protective capacities during airway disease. One source for immune-competent cells is the pleural space, however, its immune-physiological function remains poorly understood. The aim of this study was to develop an experimental technique in rodents that allows for an in vivo analysis of pleural space immune cells participating in the host defense during airway disease. METHODS I developed an easy and reliable technique that I named the "InterCostal Approach of the Pleural Space" (ICAPS) model that allows for in vivo analysis of pleural space immune cells in rodents. By injection of immune cell altering fluids into or flushing of the pleural space the immune response to airway infections can be manipulated. RESULTS The results reveal that (i) the pleural space cellular environment can be altered partially or completely as well as temporarily or permanently, (ii) depletion of pleural space cells leads to increased airway inflammation during pulmonary infection, (iii) the pleural space contributes immune competent B cells during airway inflammation and (iv) inhibition of B cell function results in reduced bacterial clearance during pneumonia. CONCLUSION As the importance for in-depth knowledge of participating immune cells during health and disease evolves, the presented technique opens new possibilities to experimentally elucidate immune cell function, trafficking and contribution of pleural space cells during airway diseases.
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Affiliation(s)
- Georg F Weber
- Department of Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany. .,Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Andreasen JJ, Sørensen GV, Abrahamsen ER, Hansen-Nord E, Bundgaard K, Bendtsen MD, Troelsen P. Early chest tube removal following cardiac surgery is associated with pleural and/or pericardial effusions requiring invasive treatment. Eur J Cardiothorac Surg 2015; 49:288-92. [DOI: 10.1093/ejcts/ezv005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/06/2015] [Indexed: 11/14/2022] Open
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