1
|
Lobdell KW, Perrault LP, Drgastin RH, Brunelli A, Cerfolio RJ, Engelman DT. Drainology: Leveraging research in chest-drain management to enhance recovery after cardiothoracic surgery. JTCVS Tech 2024; 25:226-240. [PMID: 38899104 PMCID: PMC11184673 DOI: 10.1016/j.xjtc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Kevin W. Lobdell
- Sanger Heart & Vascular Institute, Wake Forest University School of Medicine, Advocate Health, Charlotte, NC
| | - Louis P. Perrault
- Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | | | - Alessandro Brunelli
- Department of Thoracic Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom
| | | | - Daniel T. Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass
| |
Collapse
|
2
|
Kent MS, Mitzman B, Diaz-Gutierrez I, Khullar OV, Fernando HC, Backhus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Raymond DP, Schumacher L, Hayanga JWA. The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains After Pulmonary Lobectomy: Expert Consensus Document. Ann Thorac Surg 2024:S0003-4975(24)00342-4. [PMID: 38723882 DOI: 10.1016/j.athoracsur.2024.04.016] [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: 10/30/2023] [Revised: 03/16/2024] [Accepted: 04/16/2024] [Indexed: 07/04/2024]
Abstract
The Society of Thoracic Surgeons Workforce on Evidence-Based Surgery provides this document on management of pleural drains after pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in 5 specific areas: (1) choice of drain, including size, type, and number; (2) management, including use of suction vs water seal and criteria for removal; (3) imaging recommendations, including the use of daily and postpull chest roentgenograms; (4) use of digital drainage systems; and (5) management of prolonged air leak. To formulate the consensus statements, a task force of 15 general thoracic surgeons was invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of 2 rounds of voting until 75% agreement on the statements was reached. A total of 13 consensus statements are provided to encourage standardization and stimulate additional research in this important area.
Collapse
Affiliation(s)
- Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Brian Mitzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Onkar V Khullar
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Hiran C Fernando
- Division of Thoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Leah Backhus
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St James's University Hospital, Leeds, United Kingdom
| | - Stephen D Cassivi
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Traves D Crabtree
- Division of Thoracic Surgery, Southern Illinois University, Springfield, Illinois
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Linda W Martin
- Division of Thoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lana Schumacher
- Division of Thoracic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| |
Collapse
|
3
|
Heidel JS, Miller J, Donovan E, Handa R, Van Haren R, Salfity H, Starnes SL. Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection. J Thorac Cardiovasc Surg 2024; 167:517-525.e2. [PMID: 37236600 DOI: 10.1016/j.jtcvs.2023.05.017] [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: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVES The need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients. METHODS Patients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses. RESULTS A total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion. CONCLUSIONS Reserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.
Collapse
Affiliation(s)
- Justin S Heidel
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - James Miller
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Eileen Donovan
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Rahul Handa
- Division of Cardiothoracic Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Robert Van Haren
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Hai Salfity
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Sandra L Starnes
- Section of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio.
| |
Collapse
|
4
|
Schnuck JK, Acker SN, Kelley-Quon LI, Lee JH, Shew SB, Fialkowski E, Ignacio RC, Melhado C, Qureshi FG, Russell KW, Rothstein DH. Decision-Making in Pleural Drainage Following Lung Resection in Children: A Western Pediatric Surgery Research Consortium Survey. J Pediatr Surg 2024:S0022-3468(24)00009-5. [PMID: 38355336 DOI: 10.1016/j.jpedsurg.2024.01.006] [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: 11/02/2023] [Revised: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Studies of adults undergoing lung resection indicated that selective omission of pleural drains is safe and advantageous. Significant practice variation exists for pleural drainage practices for children undergoing lung resection. We surveyed pediatric surgeons in a 10-hospital research consortium to understand decision-making for placement of pleural drains following lung resection in children. METHODS Faculty surgeons at the 10 member institutions of the Western Pediatric Surgery Research Consortium completed questionnaires using a REDCap survey platform. Descriptive statistics and bivariate analyses were used to characterize responses regarding indications and management of pleural drains following lung resection in pediatric patients. RESULTS We received 96 responses from 109 surgeons (88 %). Most surgeons agreed that use of a pleural drain after lung resection contributes to post-operative pain, increases narcotic use, and prolongs hospitalization. Opinions varied around the immediate use of suction compared to water seal, and half routinely completed a water seal trial prior to drain removal. Surgeons who completed fellowship within the past 10 years left a pleural drain after wedge resection in 45 % of cases versus 78 % in those who completed fellowship more than 10 years ago (p = 0.001). The mean acceptable rate of unplanned post-operative pleural drain placement when pleural drainage was omitted at index operation was 6.3 % (±4.6 %). CONCLUSIONS Most pediatric surgeons use pleural drainage following lung resection, with recent fellowship graduates more often omitting it. Future studies of pleural drain omission demonstrating low rates of unplanned postoperative pleural drain placement may motivate practice changes for children undergoing lung resection. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Jamie K Schnuck
- Department of General Surgery, University of Washington, Seattle, WA, USA
| | - Shannon N Acker
- Department of General Surgery, Children's Hospital Colorado, Denver, CO, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Justin H Lee
- Department of General Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Stephen B Shew
- Department of General Surgery, Lucile Packard Children's Hospital, Stanford, CA, USA
| | | | - Romeo C Ignacio
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Caroline Melhado
- Department of Surgery, University of California San Francisco School of Medicine, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Faisal G Qureshi
- Division of Pediatric Surgery, University of Texas Southwestern and Children's Medical Center, Dallas, TX, USA
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - David H Rothstein
- Department of General Surgery, University of Washington, Seattle, WA, USA; Division of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA.
| |
Collapse
|
5
|
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: 0] [Impact Index Per Article: 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.
Collapse
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
| |
Collapse
|
6
|
Are Routine Chest X-rays Necessary following Thoracic Surgery? A Systematic Literature Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14184361. [PMID: 36139521 PMCID: PMC9496662 DOI: 10.3390/cancers14184361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/03/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
Abstract
Simple Summary X-rays of the chest have become part of the clinical routine for patients undergoing surgery of the chest. Each of these X-rays exposes the patient and the medical staff to radiation, increasing the treatment costs and the workload. The scientific evidence for performing X-rays after chest surgery (excluding heart surgery) is limited. The purpose of this study was to gather the evidence and analyze it in order to find out how often these X-rays have consequences or lead to a change in patient care. The results of this study could potentially help reduce the number of X-rays that are routinely performed following surgery of the chest. Abstract (1) Background: The number of chest X-rays that are performed in the perioperative window of thoracic surgery varies. Many clinics X-ray patients daily, while others only perform X-rays if there are clinical concerns. The purpose of this study was to assess the evidence of perioperative X-rays following thoracic surgery and estimate the clinical value with regard to changes in patient care. (2) Methods: A systematic literature research was conducted up until November 2021. Studies reporting X-ray outcomes in adult patients undergoing general thoracic surgery were included. (3) Results: In total, 11 studies (3841 patients/4784 X-rays) were included. The X-ray resulted in changes in patient care in 488 cases (10.74%). In patients undergoing mediastinoscopic lymphadenectomy or thoracoscopic sympathectomy, postoperative X-ray never led to changes in patient care. (4) Conclusions: There are no data to recommend an X-ray before surgery or to recommend daily X-rays. X-rays immediately after surgery seem to rarely have any consequences. It is probably reasonable to keep requesting X-rays after drain removal since they serve multiple purposes and alter patient care in 7.30% of the cases.
Collapse
|