External Suction and Fluid Output in Chest Drains After Lobectomy: A Randomized Clinical Trial

Efficacy of nil per oral, total parenteral nutrition, milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery

OBJECTIVE

A single centre experience with chylothorax in post cardiac surgical patients.

METHODS

Retrospective review.

RESULTS

Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1-995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011-2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016-2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)].

SUMMARY

In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.

Comparison of the LigaSure™ bipolar vessel sealer to monopolar electrocoagulation for thoracoscopic lobectomy and lymphadenectomy: a prospective randomized controlled trial

BACKGROUND

High-energy devices allow better vessel sealing compared with monopolar electrocautery and could improve the outcomes of surgical operations. The objective of the study was to compare tissue dissection by the LigaSure™ device with that by monopolar electrocoagulation for thoracoscopic lobectomy and lymphadenectomy.

METHODS

This pragmatic, parallel group, prospective randomized controlled trial was funded by the Medtronic External Research Program (ISR-2016-10,756) and registered at www.

CLINICALTRIALS

gov (NCT03125798). The study included patients aged 18 years or older, who had undergone thoracoscopic lobectomy with lymphadenectomy at the Department of Thoracic Surgery of Poznan University of Medical Sciences between May 3, 2018, and November 4, 2021. Using simple randomization, the patients were assigned to undergo tissue dissection with either the LigaSure device (study group) or monopolar electrocautery (control group). Participants and care givers, except operating surgeons, were blinded to group assignment. The primary outcome was postoperative chest drainage volume. Secondary outcomes were change of the esophageal temperature during subcarinal lymphadenectomy and C-reactive protein level 72 h after surgery.

RESULTS

Study outcomes were analyzed in 107 patients in each group. We found no differences between the study and control groups in terms of chest drainage volume (550 vs. 600 mL, respectively; p = 0.315), changes in esophageal temperature (- 0.1 °C vs. - 0.1 °C, respectively; p = 0.784), and C-reactive protein levels (72.8 vs. 70.8 mg/L, respectively; p = 0.503). The mean numbers of lymph nodes removed were 12.9 (SD: 3.1; 95% CI, 12.4 to 13.5) in the study group and 11.6 (SD: 3.2; 95% CI, 11.0 to 12.2) in the control group (p < 0.001).

CONCLUSIONS

The use of the LigaSure device did not allow to decrease the chest drainage volume, local thermal spread, and systemic inflammatory response. The number of lymph nodes removed was higher in patients operated with the LigaSure device, which indicated better quality of lymphadenectomy.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

A simple size-tailored algorithm for the removal of chest drain following minimally invasive lobectomy: a prospective randomized study

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).

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

What is the optimal level of suction on digital chest drainage devices following pulmonary lobectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: what is the optimal level of suction on digital chest drainage devices following pulmonary lobectomy? Altogether 367 papers were found using the reported search, of which 4 randomized controlled trials using digital chest drainage devices represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The new digital drainage systems enhance early mobilization as recommended in the enhanced recovery after surgery programme. There is, however, no consensus on the optimal level of suction to apply after pulmonary lobectomy. This is especially the case for digital drainage devices. Surgeon preference will likely continue to guide practice, until the evidence gives clear-cut recommendations. According to the current data, a low suction reduces total fluid drainage and perhaps air leak duration compared to higher suction levels in both video-assisted thoracoscopic surgery and open pulmonary lobectomies using digital drainage devices, although the evidence is not overwhelming.

Early postoperative day 0 chest tube removal using a digital drainage device protocol after thoracoscopic major pulmonary resection

OBJECTIVES

The aim of this study was to assess the safety of early chest tube removal on postoperative day 0 (POD 0) on the basis of a digital drainage device protocol in patients undergoing thoracoscopic major lung resection and its contribution as a component of an enhanced recovery after surgery programme.

METHODS

One hundred consecutive patients who underwent thoracoscopic lobectomy or segmentectomy were submitted to the following criteria for chest tube removal: Air flow ≤20 ml/min for at least 4 h without fluid threshold, except if haemorrhagic or chylous. Two groups were defined according to chest tube removal on POD 0 (G0) or POD ≥1 (G1). Primary outcome was pleural complication and secondary outcomes were cardiopulmonary complication, length of drainage, length of stay (LOS), compliance with opioid-free analgesic protocol and readmission. The follow-up was 90 days from discharge.

RESULTS

The chest tube was removed on POD 0 in 45% of patients (G0). None of them required tube reinsertion for pneumothorax and 1 patient was readmitted for a delayed pleural effusion. Among the 55% remaining patients (G1), the median length of drainage was 2 days, including 3 prolonged air leaks (>5 days). G0 and G1 were not different in terms of cardiopulmonary complication and readmission (6.6% vs 9% and 4.4% vs 7.2%, respectively). The median LOS was 1 day in G0 and 2 days in G1. The compliance with opioid-free analgesic protocol was significantly higher (75% vs 45%, P = 0.004) in G0 compared to G1.

CONCLUSIONS

Early POD 0 chest tube removal after thoracoscopic major pulmonary resection is safe in selected patients on the basis of a digital drainage device protocol. Also, it may contribute, by reducing early postoperative pain, to enhance postoperative recovery as part of an advanced enhanced recovery after surgery programme.

Single versus double chest drains after pulmonary lobectomy: a systematic review and meta-analysis

Background

Previous randomized controlled trials have compared the efficacy and safety of single chest drain (SCD) and double chest drains (DCD) in the patients undergone pulmonary lobectomy, yet the results remain inconsistent. Therefore, we aimed to conduct this present systematic review and meta-analysis to evaluate the role of SCD and DCD in the patients undergone pulmonary lobectomy.

Methods

PubMed, Medline, EMBASE, Cochrane library, Web of Science, China National Knowledge Infrastructure, Wanfang, Weipu, and China Biomedical Literature databases were searched up to February 28, 2020, to identify the potential RCTs on SCD and DCD in the patients undergone pulmonary lobectomy. The main outcomes including verbal pain score, the duration of drainage (days), the length of hospital stay (days), and the incidence of air leak and re-drainage were collected and analyzed. All the data were processed and analyzed with software RevMan 5.3. We calculated and analyzed the odds ratios (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes.

Results

A total of 11 RCTs with 1214 patients were included, in which 589 patients received SCD treatment and 625 patients DCD treatment. The verbal pain score (MD = − 0.54, 95%CI (− 0.87, − 0.21)), the duration of drainage (MD = − 0.65, 95%CI (− 1.04, − 0.26)), and the length of hospital stay (MD = − 0.55, 95%CI (− 0.80, − 0.29)) in SCD group were significantly less than that of DCD group. There were no significant differences on the incidence of air leak (OR = 1.35, 95%CI (0.86, 2.11)) and re-drainage (OR = 0.88, 95%CI (0.41, 1.90)) among the two groups.

Conclusions

SCD is a safe option, and it has the advantages of less postoperative pain, shortened duration of drain, and reduced length of hospital stay when compared with DCD in the patients undergone pulmonary lobectomy.

Early Identification of Patients Who Will Meet 24-Hour Fluid Output Threshold for Chest Tube Removal After Lung Resection

Improving evidence-based chest tube removal may reduce the length of stay following surgery. Presently, most chest tube removal protocols include a fluid output threshold based on a 24-hour observation period. The purpose of this study was to evaluate if, within a 24-hour time period, fluid output measurements at 6, 8, and 12 hours could predict if the total 24-hour fluid output would comply with a predetermined volume threshold considered acceptable for safe chest tube removal. Following lung resection, pleural fluid output data were prospectively recorded by a digital drainage system and analyzed retrospectively. Twenty-four-hour fluid output was calculated from every available 6-, 8-, and 12-hour measurement and compared to set 24-hour output criteria for chest tube removal (ie, 400 mL, 250 mL, and 20% of whole-body lymphatic flow). Performance of interim fluid outputs in predicting whether 24-hour fluid output criteria were satisfied was measured. From 2015 to 2018, 150 patients had digital pleural fluid drainage data suitable for analysis. Performance of interim fluid output data in identifying which patients would satisfy 24-hour output criteria ranged from 85% (95% confidence interval [CI] = 83-86) to 94% (95% CI = 93-94) for specificity, 75% (95% CI = 73-76) to 92% (95% CI = 90-93) for positive predictive value, and 6% (95% CI = 6-7) to 15% (95% CI = 14-17) for false-positive rate. Potential time saved in duration of drainage using interim fluid output data ranged from 10 to 16 hours. Pleural fluid output measured for 6-, 8-, and 12-hour durations can accurately identify patients who will meet 24-hour fluid output threshold for safe chest tube removal.