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Lione L, Busetto A, Verzeletti V, Cannone G, Bonis A, Berni A, Gasparini D, Mammana M, Rebusso A, Nicotra S, Gregori D, Dell’Amore A, Rea F. Thoracic Ultrasound as an Alternative to Chest X-ray in Thoracic Surgery Patients: A Single-Center Experience. J Clin Med 2024; 13:3663. [PMID: 38999229 PMCID: PMC11242563 DOI: 10.3390/jcm13133663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Chest X-ray (CXR) is currently the most used investigation for clinical follow-up after major noncardiac thoracic surgery. This study explores the use of lung ultrasound (LUS) as an alternative to CXR in the postoperative management of patients who undergo major thoracic procedures. Methods: The patients in our cohort were monitored with both a CXR and a lung ultrasonography after surgery and the day after chest drain removal. The LUS was performed by a member of the medical staff of our unit who was blinded to both the images and the radiologist's report of the CXR. Findings were compared between the two methods. Results: In the immediate postoperative evaluation, 280 patients were compared, finding general agreement between the two procedures at 84% (kappa statistic, 0.603). The LUS showed a sensibility of 84.1%, a specificity of 84.3%, a positive predictive value (PPV) of 60.9%, and a negative predictive value (NPV) of 94.8%. We evaluated 219 out of 280 patients in the postdrainage-removal setting due to technical issues. Concordance between the methods in the postdrainage-removal setting was 89% (kappa statistic, 0.761) with the LUS demonstrating an 82.2% sensibility, a 93.2% specificity, a PPV of 85.7%, and an NPV of 91.3%. Conclusions: The results of this study showed a substantial agreement between LUS and CXR, suggesting that the LUS could reduce the number of X rays in certain conditions. The high NPV allows for the exclusion of PNX and pleural effusion without the need to expose patients to radiation. Discrepancies were noted in cases of mild pneumothorax or modest pleural effusion, without altering the clinical approach.
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Affiliation(s)
- Luigi Lione
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Alberto Busetto
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Vincenzo Verzeletti
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Giorgio Cannone
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Alessandro Bonis
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Alessandro Berni
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Daniele Gasparini
- Unit of Biostatistics, Epidemiology and Public Health, University of Padua, Via L. Loredan 18, 35131 Padova, Italy; (D.G.); (D.G.)
| | - Marco Mammana
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Alessandro Rebusso
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Samuele Nicotra
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, University of Padua, Via L. Loredan 18, 35131 Padova, Italy; (D.G.); (D.G.)
| | - Andrea Dell’Amore
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
| | - Federico Rea
- Thoracic Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via N. Giustiniani, 2, 35121 Padova, Italy; (A.B.); (V.V.); (G.C.); (A.B.); (A.B.); (M.M.); (A.R.); (S.N.); (F.R.)
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Thet MS, Han KPP, Hlwar KE, Thet KS, Oo AY. Efficacy of chest X-rays after drain removal in adult and pediatric patients undergoing cardiac and thoracic surgery: A systematic review. J Card Surg 2022; 37:5320-5325. [PMID: 36335600 PMCID: PMC10099874 DOI: 10.1111/jocs.17114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Chest X-rays are routinely obtained after the removal of chest drains in patients undergoing cardiac and thoracic surgical procedures. However, a lack of guidelines and evidence could question the practice. Routine chest X-rays increase exposure to ionizing radiation, increase health-care costs, and lead to overutilisation of available resources. This review aims to explore the evidence in the literature regarding the routine use of chest X-rays following the removal of chest drains. MATERIALS & METHOD A systematic literature search was conducted in PubMed, Medline via Ovid, Cochrane central register of control trials (CENTRAL), and ClinicalTrials. gov without any limit on the publication year. The references of the included studies are manually screened to identify potentially eligible studies. RESULTS A total of 375 studies were retrieved through the search and 18 studies were included in the review. Incidence of pneumothorax remains less than 10% across adult cardiac, and pediatric cardiac and thoracic surgical populations. The incidence may be as high as 50% in adult thoracic surgical patients. However, the reintervention rate remains less than 2% across the populations. Development of respiratory and cardiovascular symptoms can adequately guide for a chest X-ray following the drain removal. As an alternative, bedside ultrasound can be used to detect pneumothorax in the thorax after the removal of a chest drain without the need for ionizing radiation. CONCLUSION A routine chest X-ray following chest drain removal in adult and pediatric patients undergoing cardiac and thoracic surgery is not necessary. It can be omitted without compromising patient safety. Obtaining a chest X-ray should be clinically guided. Alternatively, bedside ultrasound can be used for the same purpose without the need for radiation exposure.
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Affiliation(s)
- Myat S Thet
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Khin P P Han
- Mandalay General Hospital, University of Medicine, Mandalay, Myanmar
| | - Khun E Hlwar
- Mandalay General Hospital, University of Medicine, Mandalay, Myanmar
| | - Khaing S Thet
- Mandalay General Hospital, University of Medicine, Mandalay, Myanmar
| | - Aung Y Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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Hsu DS, Banks KC, Jiang SF, Phillips JL, Ely S, Heinz BB, Maxim CL, Ashiku SK, Patel AR, Velotta JB. Routine Post-pull Chest Radiograph is Not Necessary After VATS Lobectomy. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Impact of routine chest radiographs after removal of pigtail chest tubes placed by pediatric interventional radiology. Pediatr Radiol 2022; 52:971-976. [PMID: 35076728 DOI: 10.1007/s00247-021-05265-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/17/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chest radiographs are commonly obtained after chest tube removal to assess for complications. The benefit of this practice in children is uncertain. OBJECTIVE To determine the clinical impact of a routine chest radiograph following removal of chest tubes placed by pediatric interventional radiology. MATERIALS AND METHODS This single-center retrospective study evaluated 200 chest tube removals in 176 patients (median age: 4 years, interquartile range [IQR]: 1.2-12; median weight: 17.2 kg, IQR: 10.67-37.6), who had a chest tube placed and removed by pediatric interventional radiology over a 16-year period. A chest radiograph obtained on the day of removal was compared to the preceding study. For patients with imaging changes, medical records were reviewed to determine whether clinical actions occurred as a result. All records were reviewed for 7 days after tube removal or hospital discharge, whichever occurred first. RESULTS The most common indication for chest tube insertion was simple effusion (53%, 106/200) and the most common tube size was 10.2 French (38.7%, 81/209). The median tube dwell time was 8 days (IQR: 5-17). There was a median of 14 h (IQR: 7-33.5) between imaging before and after tube removal. Imaging changes occurred in 10% (n = 20/200) of chest tube removals. Three of 200 (1.5%) of these were symptomatic after removal and only 0.5% (1/200) required chest tube reinsertion. For the remaining removals resulting in chest radiograph changes, patients were asymptomatic and required no change in clinical management. CONCLUSION For chest tubes placed by pediatric interventional radiology, these findings do not support the practice of a routine chest radiograph after removal in asymptomatic children.
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Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, Hofmann BM. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging 2022; 22:73. [PMID: 35448987 PMCID: PMC9022417 DOI: 10.1186/s12880-022-00798-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020208072.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Eivind Richter Andersen
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Arne Magnus Krokeide
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Lesley J J Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Leti van Bodegom-Vos
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fiona M Clement
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics, The University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
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Zukowski M, Haas A, Schaefer EW, Shen C, Reed MF, Taylor MD, Go PH. Are Routine Chest Radiographs After Chest Tube Removal in Thoracic Surgery Patients Necessary? J Surg Res 2022; 276:160-167. [PMID: 35344742 DOI: 10.1016/j.jss.2022.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The routine use of chest x-ray (CXR) to evaluate the pleural space after chest tube removal is a common practice driven primarily by surgeon preference and institutional protocol. The results of these postpull CXRs frequently lead to additional interventions that serve only to increase health care costs and resource utilization. We investigated the utility of these postpull CXRs in thoracic surgery patients and assessed their effectiveness in predicting the need for tube replacement. METHODS Single-institution retrospective study comprising thoracic surgery patients requiring postoperative chest tube drainage over a 3-y period. Demographics and surgical characteristics, including surgical approach, procedure, and procedure type, were recorded. Outcomes included postpull CXR findings, interventions resulting from radiographic abnormalities, and the additional health resource utilization incurred by obtaining these studies on asymptomatic patients. RESULTS The study included 433 patients. Postpull CXRs were performed in 87.1% of patients, with 33.2% demonstrating an abnormality compared with the prior study. Among these, 65.7% resulted only in repeat imaging and 25.7% resulted in discharge delay. Overall, a total of 13 patients (3%) required chest tube replacement, three during the index hospitalization and the other 10 requiring readmission. Among those requiring chest tube replacement, 75% had normal postpull imaging, and all were symptomatic. CONCLUSIONS Recurrent pneumothorax after chest tube removal requiring immediate tube reinsertion is relatively rare and does not occur in the absence of symptoms. Our study suggests that routine postpull CXRs have limited clinical utility and can be safely omitted in asymptomatic patients with appropriate clinical observation.
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Affiliation(s)
- Monica Zukowski
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Alec Haas
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Eric W Schaefer
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Chan Shen
- Division of Outcomes, Research & Quality, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Division of Health Services and Behavioral Research, Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Michael F Reed
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Matthew D Taylor
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Pauline H Go
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Division of Thoracic Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
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Dezube AR, Deeb A, De Leon LE, Kucukak S, Marshall MB, Jaklitsch MT, Rochefort MM. Routine Chest X-ray After Chest Tube Removal Is Not Indicated for Minimally Invasive Lung Resection. Ann Thorac Surg 2021; 114:2108-2114. [PMID: 34798074 DOI: 10.1016/j.athoracsur.2021.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/18/2021] [Accepted: 10/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chest x-rays after chest tube removal are common practice in post-operative thoracic surgery patients. Whether these x-rays change clinical management is debatable. We investigated prevalence and management of post-pull pneumothoraces following lung resection. METHODS Retrospective review of minimally-invasive wedge-resections, segmentectomies, and lobectomies between March 2018 and September 2018. Baseline factors, operative technique, chest tube management, and outcomes following post-pull chest x-ray and factors associated with post-pull pneumothoraces were analyzed. RESULTS 200 consecutive patients were analyzed: 117 wedge-resections (59%), 24 segmentectomies (12%), and 59 lobectomies (30%). Wedge-resections compared to segmentectomy or lobectomy had lower rates of chest tube usage, drain duration, air-leaks, and need for clamp-trial, with Blake drains most often removed last compared to segmentectomy or lobectomy (all <0.001). 110 patients (55%) experienced a post-pull pneumothorax, which were largely small/tiny/trace (96%). 5 patients experienced symptoms and no patients required intervention. Resection type was associated with pneumothorax rate, need for additional imaging, and discharge timing (all p<0.05). Those with pneumothoraces compared to those without differed in type of resection and chest drain, presence of air-leak within 24 hours of removal, need for clamp trial, order of tube removal, and hospital length of stay (all p<0.05). Multivariable regression showed only clamp trial was associated with post-pull pneumothorax development (OR 2.48 95% CI 1.13-5.45; p=0.024). CONCLUSIONS While routine use of post-pull chest x-ray identified a high prevalence of pneumothorax, no intervention was required. Our study demonstrates post-pull imaging may not be indicated in asymptomatic patients without prior air leak or clamp trial.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA.
| | - Ashley Deeb
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Luis E De Leon
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Suden Kucukak
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - M Blair Marshall
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael T Jaklitsch
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Matthew M Rochefort
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
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Theodorou CM, Hegazi MS, Moore HN, Beres AL. Routine chest X-rays after pigtail chest tube removal rarely change management in children. Pediatr Surg Int 2021; 37:1447-1451. [PMID: 34173055 PMCID: PMC8408085 DOI: 10.1007/s00383-021-04951-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The need for chest X-rays (CXR) following large-bore chest tube removal has been questioned; however, the utility of CXRs following removal of small-bore pigtail chest tubes is unknown. We hypothesized that CXRs obtained following removal of pigtail chest tubes would not change management. METHODS Patients < 18 years old with pigtail chest tubes placed 2014-2019 at a tertiary children's hospital were reviewed. Exclusion criteria were age < 1 month, death or transfer with a chest tube in place, or pigtail chest tube replacement by large-bore chest tube. The primary outcome was chest tube reinsertion. RESULTS 111 patients underwent 123 pigtail chest tube insertions; 12 patients had bilateral chest tubes. The median age was 5.8 years old. Indications were pneumothorax (n = 53), pleural effusion (n = 54), chylothorax (n = 6), empyema (n = 5), and hemothorax (n = 3). Post-pull CXRs were obtained in 121/123 cases (98.4%). The two children without post-pull CXRs did not require chest tube reinsertion. Two patients required chest tube reinsertion (1.6%), both for re-accumulation of their chylothorax. CONCLUSIONS Post-pull chest X-rays are done nearly universally following pigtail chest tube removal but rarely change management. Providers should obtain post-pull imaging based on symptoms and underlying diagnosis, with higher suspicion for recurrence in children with chylothorax.
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Affiliation(s)
- Christina M. Theodorou
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817 USA
| | - Mennatalla S. Hegazi
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, CA USA
| | - Hope Nicole Moore
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, CA USA
| | - Alana L. Beres
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, CA USA
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Hafezi N, Cromeens BP, Morocho BS, Raymond JL, Landman MP. Thoracostomy Tube Removal in Pediatric Trauma: Film or No Film? J Surg Res 2021; 269:51-58. [PMID: 34520982 DOI: 10.1016/j.jss.2021.06.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/24/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Use of routine chest x-rays (CXR) following thoracostomy tube (TT) removal is highly variable and its utility is debated. We hypothesize that routine post-pull chest x-ray (PP-CXR) findings following TT removal in pediatric trauma would not guide the decision for TT reinsertion. METHODS Patients ≤ 18 y who were not mechanically ventilated and undergoing final TT removal for a traumatic hemothorax (HTX) and/or pneumothorax (PTX) at a level I pediatric trauma center from 2010 to 2020 were retrospectively reviewed. The outcomes of interest were rate of PP-CXR and TT reinsertion rate following PP-CXR. Clinical predictors for worsened findings on PP-CXR were also assessed. RESULTS Fifty-nine patients were included. A CXR after TT removal was performed in 57 patients (97%), with 28% demonstrating worsened CXR findings compared to the prior film. Except for higher ISS (p = 0.033), there were no demographic or clinical predictors for worsened CXR findings. However, they were more likely to have additional films following the TT removal (p = 0.008) than those with stable or improved PP-CXR findings. One (1.8%) asymptomatic child with worsened PP-CXR findings had TT reinsertion based purely on their worsened PP-CXR findings. CONCLUSIONS The vast majority of PP-CXR did not guide TT reinsertion after pediatric thoracic trauma. Treatment algorithms may aid to reduce variability and potentially unnecessary routine films.
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Affiliation(s)
- Niloufar Hafezi
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Barrett P Cromeens
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Bryant S Morocho
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, PA
| | - Jodi L Raymond
- Riley Trauma Program, Riley Hospital for Children, Indiana University Health, Indianapolis, IN
| | - Matthew P Landman
- Department of Surgery, Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN; Riley Trauma Program, Riley Hospital for Children, Indiana University Health, Indianapolis, IN.
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Sweet AAR, Beks RB, de Jong MB, van Baal MCPM, IJpma FFA, Hietbrink F, Beeres FJP, Leenen LPH, Groenwold RHH, Houwert RM. Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review. J Trauma Acute Care Surg 2021; 91:427-434. [PMID: 33605708 DOI: 10.1097/ta.0000000000003118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients. METHODS A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal. RESULTS Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention. CONCLUSION In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed. LEVEL OF EVIDENCE Systematic review study, level IV.
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Affiliation(s)
- Arthur A R Sweet
- From the Department of Surgery (A.A.R.S., M.B.d.J., M.C.P.v.B., F.H., L.P.H.L., R.M.H.), University Medical Center Utrecht, Utrecht; Department of Surgery (R.B.B.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Surgery (F.F.A.I.), University Medical Center Groningen, Groningen, the Netherlands; Department of Orthopedics and Trauma Surgery (F.J.P.B.), Luzerner Kantonsspital, Luzern, Switzerland; Department of Clinical Epidemiology (R.H.H.G.), Leiden University Medical Center, Leiden, the Netherlands
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11
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Kanamori LM, Guner Y, Gibbs D, Schomberg J. Are routine chest X-rays following chest tube removal necessary in asymptomatic pediatric patients? Pediatr Surg Int 2021; 37:631-637. [PMID: 33385243 DOI: 10.1007/s00383-020-04809-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to determine if routine chest X-rays (CXRs) performed after chest tube (CT) removal in pediatric patients provide additional benefit for clinical management compared to observation of symptoms alone. METHODS A single-center retrospective study was conducted of inpatients, 18 years or younger, who had a CT managed by the pediatric surgery team between July 2017 and May 2019. The study compared two groups: (1) patients who received a post-pull CXR and (2) those who did not. The primary outcome of the study was the need for intervention after CT removal. RESULTS 102 patients had 116 CTs and met inclusion criteria; 79 post-pull CXRs were performed; the remaining 37 CT pulls did not have a follow-up CXR. No patients required CT replacement or surgery in the absence of symptoms. Three patients exhibited clinical symptoms that would have prompted intervention regardless of post-pull CXR results. One patient had an intervention guided by post-pull CXR results alone. Meanwhile, another patient had delayed onset of symptoms and intervention. No patients required an intervention in the group that did not have a post-pull CXR. CONCLUSION Chest X-ray after CT removal had a very low yield for changing clinical management of asymptomatic patients. Clinical symptoms predict the need for an intervention.
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Affiliation(s)
- Lauren M Kanamori
- Division of Pediatric General, Thoracic and Trauma Surgery, CHOC Children's Hospital of Orange County, 505 South Main Street, Suite 225, Orange, CA, 92868, USA.
| | - Yigit Guner
- Division of Pediatric General, Thoracic and Trauma Surgery, CHOC Children's Hospital of Orange County, University of California, Irvine Medical Center, Department of Surgery, 505 South Main Street, Suite 225, Orange, CA, 92868, USA
| | - David Gibbs
- Division of Pediatric General, Thoracic and Trauma Surgery, CHOC Children's Hospital of Orange County, University of California, Irvine Medical Center, Department of Surgery, 505 South Main Street, Suite 225, Orange, CA, 92868, USA
| | - John Schomberg
- Department of Clinical Education and Professional Development, CHOC Children's Hospital of Orange County, 1201 W. La Veta Avenue, Orange, CA, 92868, USA
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12
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Galetin T, Merres J, Schieren M, Marks B, Haffke Y, Defosse J, Wappler F, Koryllos A, Stoelben E. Most patient conditions do not a priori debilitate the sensitivity of thoracic ultrasound in thoracic surgery-a prospective comparative study. J Cardiothorac Surg 2021; 16:75. [PMID: 33849605 PMCID: PMC8045207 DOI: 10.1186/s13019-021-01454-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 03/31/2021] [Indexed: 11/30/2022] Open
Abstract
Background The few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound. Methods We compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax. Results We performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population . Conclusions Most of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions. Trial registration DRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216 Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01454-6.
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Affiliation(s)
- Thomas Galetin
- Lungclinic, Thoracic Surgery, University Witten/Herdecke, Medical Centre Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - Julika Merres
- Lungclinic, Thoracic Surgery, University Witten/Herdecke, Medical Centre Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Mark Schieren
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Benjamin Marks
- Department of Radiology, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Yves Haffke
- Lungclinic, Thoracic Surgery, University Witten/Herdecke, Medical Centre Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Jerome Defosse
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Frank Wappler
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Aris Koryllos
- Lungclinic, Thoracic Surgery, University Witten/Herdecke, Medical Centre Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Erich Stoelben
- Lungclinic, Thoracic Surgery, University Witten/Herdecke, Medical Centre Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany
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13
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Routine Chest X-Rays After Thoracic Surgery Are Unnecessary. J Surg Res 2020; 250:188-192. [DOI: 10.1016/j.jss.2019.12.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/19/2019] [Accepted: 12/30/2019] [Indexed: 12/13/2022]
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14
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Parker MH, Newcomb AB, Liu C, Michetti CP. Chest Tube Management Practices by Trauma Surgeons. J Surg Res 2019; 244:225-230. [PMID: 31301478 DOI: 10.1016/j.jss.2019.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/30/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Chest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers. MATERIALS AND METHODS We designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used. RESULTS The response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice. CONCLUSIONS Trauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.
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Affiliation(s)
- Michael H Parker
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Anna B Newcomb
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Chang Liu
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia
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15
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Kingma BF, Marges OM, Van Hillegersberg R, Ruurda JP. Routine chest X-rays after the removal of chest tubes are not necessary following esophagectomy. J Thorac Dis 2019; 11:S799-S804. [PMID: 31080661 DOI: 10.21037/jtd.2018.12.74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Chest X-rays (CXRs) are commonly performed after removing chest tubes following surgery. However, the value of this practice is unclear for patients who underwent esophagectomy. Therefore, the aim of this study was to investigate the clinical relevance of routinely performing a CXR after chest tube removal during the postoperative course of esophagectomy. Methods A single-center prospective database was used to select all patients who underwent esophagectomy with gastric conduit reconstruction between 2015 and 2017. Patients who received a CXR within 4 hours after removal of at least one chest tube were included. The radiological reports of these CXRs were evaluated for intrapleural air and fluid. Cases requiring re-insertion of a chest tube on the day of CXR or the day afterwards were identified and the clinical situation of these patients was reviewed. Results Some 117 patients were included and a total of 231 chest tube removals were followed by a CXR within 4 hours. Re-insertion of a chest tube was performed in a total of 6 cases (3%) on the day or the day after this CXR. All these 6 patients had clinical signs or symptoms indicating respiratory problems. In total, new intrapleural air was found on the ipsilateral side of previous chest tube removal in 33 cases (14%) and new intrapleural fluid occurred on the ipsilateral side of previous chest tube removal in 24 cases (10%). Conclusions In conclusion, a CXR after chest tube removal may safely be reserved for patients who develop clinical signs or symptoms that indicate respiratory problems.
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Affiliation(s)
- B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Onno M Marges
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, The Netherlands
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