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Alcasid NJ, Banks KC, Jiang SF, Susai CJ, Hsu D, Carroway W, Williams K, Patel A, Ashiku S, Velotta JB. Are routine, daily chest radiographs (CXR) necessary following (VATS and RATS) lobectomies? Surg Open Sci 2024; 20:20-26. [PMID: 38873330 PMCID: PMC11169440 DOI: 10.1016/j.sopen.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
Background Consensus guidelines regarding the amount and necessity of post-operative imaging in thoracic surgery are lacking. The efficacy of daily chest radiographs (CXR) following video-assisted (VATS) and robotic-assisted (RATS) thoracoscopic surgery in directing management has not been previously studied. We hypothesize that abnormal clinical findings, rather than abnormal imaging findings, better predict post-operative complications in patients undergoing VATS/RATS lobectomies. Methods A retrospective review of VATS and RATS lobectomy patients were performed at a tertiary referral center from 1/1/2019-12/31/2021. Demographics, hospital course, and imaging were evaluated. Descriptive statistics, Chi-Square test, Fisher's exact, Wilcoxon rank sum, and multivariable logistic regression were performed. Our outcomes were post-operative complications requiring a procedure and extended length of stay (LOS) (>2 days post-operatively). Results Out of 362 VATS/RATS lobectomy patients, 15 patients had post-operative complications requiring a procedure. Almost all patients who required a procedure had abnormal clinical signs and symptoms (14/15; p < 0.001) while 70 % had expected post-operative day (POD) one CXR findings (11/15; p = 0.463). Multivariable logistic regression demonstrated clinical signs and symptoms independently predicted procedural requirement (odds ratio [OR] = 48, 95 % Confidence Interval [CI]:8.5-267) while abnormal POD one imaging did not. For extended LOS, a positive smoking history (OR = 4.4, 95 % CI:1.4-14.1), number of CXRs (OR = 2.4, 95 % CI:1.8-3.2) and thoracostomy tubes (OR = 5.3, 95 % CI:1.0-27.3) were independent predictors while clinical signs and symptoms was not. Conclusion Abnormal clinical findings may guide management more predictably than abnormal CXRs after VATS/RATS. Routine CXR in the post-operative setting may be unnecessary in those without clinical signs or symptoms. Key message There are no consensus guidelines regarding the efficacy of routine, post-operative diagnostic studies after major thoracic lobar resections. The presence of abnormal signs or symptoms after minimally invasive lobectomies may better predict those who will require additional procedures better than the presence of abnormal routine, post-operative chest radiographs.
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Affiliation(s)
- Nathan J. Alcasid
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Kian C. Banks
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Sheng-Fang Jiang
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, USA
| | - Cynthia J. Susai
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Diana Hsu
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - William Carroway
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Kenneth Williams
- University of California, San Francisco-East Bay, Department of General Surgery, Oakland, CA, USA
| | - Ashish Patel
- Kaiser Permanente Northern California, Division of Thoracic Surgery, Department of Surgery, Oakland, CA, USA
| | - Simon Ashiku
- Kaiser Permanente Northern California, Division of Thoracic Surgery, Department of Surgery, Oakland, CA, USA
| | - Jeffrey B. Velotta
- Kaiser Permanente Northern California, Division of Thoracic Surgery, Department of Surgery, Oakland, CA, USA
- University of California, San Francisco, Department of Surgery, San Francisco, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Clinical Science, Pasadena, CA, USA
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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
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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.
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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
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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.
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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.
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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: 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.
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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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Chest X-ray imaging after chest tube removal in children undergoing congenital heart surgery: May be life-saving in redo patients. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.997619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background/Aim: Parallel to the developments in congenital heart surgery, the number of children undergoing resternotomy (redo) heart surgery is increasing. In this specific group of patients, post-operative pneumothorax (PTX) and atelectasis are preventable respiratory complications. However, in the literature, pediatric data are still limited. In this study, we draw attention to the frequency and importance of PTX, a post-operative respiratory complication in redo patients. We investigate the necessity for routine chest X-rays to detect PTX following chest tube removal after closed or open-heart operations for congenital heart disease.
Methodsː A total of 554 consecutive pediatric patients who underwent cardiac surgery were analyzed. The study was designed as a retrospective cohort study. The patient’s demographic data, clinical characteristics with chest tube removal, and pathologies detected by chest X-ray were recorded. Patients were divided into non-redo and redo groups or subgroups. Patients who developed PTX (n = 24) were divided into subgroups: asymptomatic or symptomatic and large or small. Data analysis and statistical comparison between the groups were performed with independent-samples t-test or Mann-Whitney U test.
Resultsː In 24 (4.3%) of the 554 patients included in the study, PTX was detected in the post-operative evaluation after chest tube removal. Of the PTX cases, 15 (62.5%) were small, and nine (37.5%) were large. Ten (41.6%) patients were symptomatic, while nine patients had large PTX, and one patient with small PTX was identified. There were significantly more cases of large PTX in redo cases than in non-redo cases (P = 0.038). PTX was significantly more symptomatic in redo patients than non-redo patients (P = 0.031).
Conclusionː In patients undergoing cardiac surgery for the first time, a detailed clinical assessment reduces the likelihood of post-procedure PTX and makes routine chest X-ray imaging unnecessary. Conversely, clinical follow-up of these patients in terms of PTX should be essential for possible complications. However, clinical signs of late PTX development in the first 24–48 h after chest tube removal in patients undergoing redo cardiac surgery should be followed carefully by the clinician, and chest X-ray imaging should be routinely performed.
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7
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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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8
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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.
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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: 4] [Impact Index Per Article: 2.0] [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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11
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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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12
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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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13
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Laroia AT, Donnelly EF, Henry TS, Berry MF, Boiselle PM, Colletti PM, Kuzniewski CT, Maldonado F, Olsen KM, Raptis CA, Shim K, Wu CC, Kanne JP. ACR Appropriateness Criteria® Intensive Care Unit Patients. J Am Coll Radiol 2021; 18:S62-S72. [PMID: 33958119 DOI: 10.1016/j.jacr.2021.01.017] [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: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023]
Abstract
Chest radiography is the most frequent and primary imaging modality in the intensive care unit (ICU), given its portability, rapid image acquisition, and availability of immediate information on the bedside preview. Due to the severity of underlying disease and frequent need of placement of monitoring devices, ICU patients are very likely to develop complications related to underlying disease process and interventions. Portable chest radiography in the ICU is an essential tool to monitor the disease process and the complications from interventions; however, it is subject to overuse especially in stable patients. Restricting the use of chest radiographs in the ICU to only when indicated has not been shown to cause harm. The emerging role of bedside point-of-care lung ultrasound performed by the clinicians is noted in the recent literature. The bedside lung ultrasound appears promising but needs cautious evaluation in the future to determine its role in ICU patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Edwin F Donnelly
- Panel Chair, Vanderbilt University Medical Center, Nashville, Tennessee. Chief, Division of Thoracic Radiology, Department of Radiology, Ohio State University Wexner Medical Center
| | - Travis S Henry
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Mark F Berry
- Stanford University Medical Center, Stanford, California, The Society of Thoracic Surgeons
| | - Phillip M Boiselle
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | | | | | - Fabien Maldonado
- Vanderbilt University Medical Center, Nashville, Tennessee, American College of Chest Physicians
| | | | | | - Kyungran Shim
- John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, American College of Physicians
| | - Carol C Wu
- University of Texas MD Anderson Cancer Center, Houston, Texas, Chair of Thoracic Use Case Panel of ACR DSI, Deputy Chair ad interim, Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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14
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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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15
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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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16
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Porter ED, Kelly JL, Fay KA, Hasson RM, Millington TM, Finley DJ, Phillips JD. Reducing Unnecessary Chest X-Ray Films After Thoracic Surgery: A Quality Improvement Initiative. Ann Thorac Surg 2020; 111:1012-1018. [PMID: 32739255 DOI: 10.1016/j.athoracsur.2020.05.161] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/11/2020] [Accepted: 05/27/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized. METHODS A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees. RESULTS During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P < .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year. CONCLUSIONS Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing.
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Affiliation(s)
- Eleah D Porter
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Kayla A Fay
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rian M Hasson
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| | - Timothy M Millington
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| | - David J Finley
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire
| | - Joseph D Phillips
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire.
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17
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Richards A, Evans J. Are routine chest X-rays required after removal of chest drains in children? Arch Dis Child 2020; 105:700-702. [PMID: 32475819 DOI: 10.1136/archdischild-2020-318814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/18/2020] [Indexed: 11/03/2022]
Affiliation(s)
| | - Jordan Evans
- Paediatric Emergency Department, Cardiff and Vale University Health Board, Cardiff, UK
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18
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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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Bhakhri K, Coonar A. Editorial of current practise in the use of chest ultrasound in thoracic surgery. J Thorac Dis 2020; 11:5706-5707. [PMID: 32030307 DOI: 10.21037/jtd.2019.12.114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kunal Bhakhri
- Senior Thoracic Registrar, Royal Papworth Hospital, Hitchin, UK
| | - Aman Coonar
- Consultant Thoracic Surgeon, Royal Papworth Hospital, Hitchin, UK
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20
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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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21
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Scanagatta P, Rolli L. Post-operative lung ultrasonography in daily routine thoracic surgery: can we trust its results? J Thorac Dis 2019; 11:42-44. [PMID: 30863566 DOI: 10.21037/jtd.2018.12.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Paolo Scanagatta
- Division of Thoracic Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Rolli
- Division of Thoracic Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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22
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Smargiassi A, Inchingolo R, Chiappetta M, Ciavarella LP, Lopatriello S, Corbo GM, Margaritora S, Richeldi L. Agreement between chest ultrasonography and chest X-ray in patients who have undergone thoracic surgery: preliminary results. Multidiscip Respir Med 2019; 14:9. [PMID: 30867907 PMCID: PMC6398240 DOI: 10.1186/s40248-019-0171-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 01/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background Chest Ultrasonography (chest US) has shown good sensibility in detecting pneumothorax, pleural effusions and peripheral consolidations and it can be performed bedside. Objectives The aim of the study was to analyze agreement between chest US and chest X-ray in patients who have undergone thoracic surgery and discuss cases of discordance. Methods Patients undergoing thoracic surgery were retrospectively selected. Patients underwent routinely Chest X-ray (CXR) during the first 48 h after surgery. Chest US have been routinely performed in all selected patients in the same date of CXR. Chest US operators were blind to both reports and images of CXR. Ultrasonographic findings regarding pneumothorax (PNX), subcutaneous emphysema (SCE), lung consolidations (LC), pleural effusions (PE) and hemi-diaphragm position were collected and compared to corresponding CXR findings. Inter-rater agreement between two techniques was determined by Cohen's kappa-coefficient. Results Twenty-four patients were selected. Inter-rater agreement showed a moderate magnitude for PNX (Cohen's Kappa 0.5), a slight/fair magnitude for SCE (Cohen's Kappa 0.21), a fair magnitude for PE (Cohen's Kappa 0.39), no agreement for LCs (Cohen's Kappa 0.06), high levels of agreement for position of hemi-diaphragm (Cohen's Kappa 0.7). Conclusion Analysis of agreement between chest X-ray and chest US showed that ultrasonography is able to detect important findings for surgeons. Limitations and advantages have been found for both chest X-ray and chest US. Knowing the limits of each one is important to really justify and optimize the use of ionizing radiations.
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Affiliation(s)
- Andrea Smargiassi
- 1Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Inchingolo
- 1Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Chiappetta
- 2Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Stefania Lopatriello
- 1Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Maria Corbo
- 1Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,3Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Margaritora
- 2Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,3Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Richeldi
- 1Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,3Università Cattolica del Sacro Cuore, Rome, Italy
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Chiappetta M, Meacci E, Cesario A, Smargiassi A, Inchingolo R, Petracca Ciavarella L, Lopatriello S, Contegiacomo A, Congedo MT, Margaritora S. Postoperative chest ultrasound findings and effectiveness after thoracic surgery: A pilot study. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1960-1967. [PMID: 29980450 DOI: 10.1016/j.ultrasmedbio.2018.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/01/2018] [Accepted: 05/08/2018] [Indexed: 06/08/2023]
Abstract
The aim of this study was to analyze the information from post-operative chest ultrasound (CU) to evaluate the possibility to use this method instead of chest X-ray (CXR) after thoracic surgery. Patients who underwent thoracic surgery were evaluated with CU blinded to CXR after surgery, deciding if it was useful or CU was exhaustive. Twenty-four patients were enrolled prospectively. The CU allowed a further discrimination of the lung abnormalities, discriminating between atelectasis, infections or hematoma. CXR was required in only 5 cases due to the presence of massive subcutaneous emphysema or absence of lung point. In the remaining 19 cases, CU was considered exhaustive and effective. In particular, CU was considered exhaustive in 67% of cases after open surgery and in 85% of cases after video-assisted thoracic surgery. In conclusion, CU appears to be effective in post-operative management after thoracic surgery and it can increase the diagnostic accuracy reducing any unnecessary X-ray exposure.
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Affiliation(s)
- Marco Chiappetta
- Thoracic Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.
| | - Elisa Meacci
- Thoracic Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Alfredo Cesario
- Clinical Governance, Università Cattolica del sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Andrea Smargiassi
- Pulmonary Medicine Department, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Riccardo Inchingolo
- Pulmonary Medicine Department, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Leonardo Petracca Ciavarella
- Thoracic Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Stefania Lopatriello
- Pulmonary Medicine Department, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Andrea Contegiacomo
- Department of Radiology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Maria Teresa Congedo
- Thoracic Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Stefano Margaritora
- Thoracic Surgery, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
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Patella M, Saporito A, Puligheddu C, Mongelli F, La Regina D, Pini R, Inderbitzi R, Cafarotti S. Lung Ultrasound to Detect Residual Pneumothorax After Chest Drain Removal in Lung Resections. Ann Thorac Surg 2018; 105:1537-1542. [PMID: 29331648 DOI: 10.1016/j.athoracsur.2017.12.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/30/2017] [Accepted: 12/06/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Indication for postdrain removal imaging after lung resection is debated. Chest roentgenogram (CR) is widely used to confirm lung expansion but not evidence based. We propose to introduce lung ultrasound (LUS) as alternative to exclude significant pneumothorax (PTx) in this setting. METHODS The study enrolled 50 patients undergoing lung resections. Inclusion criteria were complete expansion of the lung at postoperative CR, pleural effusion of less than 300 mL/24 h, air leak of 10 to 20 mL/min for 6 hours. Two hours after chest drain removal, LUS was performed at the second and third intercostal spaces to assess pleural sliding. Patients with no detected PTx or with apical PTx were considered for discharge. The same patients were blindly evaluated with CR by a second operator, and a comparison between the two methods was performed. Clinical decisions were taken based on CR results. RESULTS LUS confirmed large PTxs in 7 patients, apical PTxs in 10 patients, and no PTx in 33 patients. CR confirmed 5 of 7 significant PTxs (1 chest drain reinserted, 4 patients observed), and 2 of 7 PTx were considered irrelevant. Apical PTxs were confirmed in 8 of 10 patients, and in 2 patients there was no PTx at CR. The 33 patients with no PTx at LUS had full lung expansion at CR. LUS has a negative predictive value of 100% in excluding large PTxs and a positive predictive value of 71%. CONCLUSIONS In this subgroup of patients with air leak of 10 to 20 mL/min, performing an imaging study to verify the absence of PTx is desirable; however, when LUS confirms lung expansion or the presence of apical PTx, CR does not seem to be needed.
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Affiliation(s)
- Miriam Patella
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland.
| | - Andrea Saporito
- Perioperative Medicine Research Group, San Giovanni Hospital, Bellinzona, Switzerland
| | - Carla Puligheddu
- Department of Radiology, San Giovanni Hospital, Bellinzona, Switzerland
| | - Francesco Mongelli
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Davide La Regina
- Perioperative Medicine Research Group, San Giovanni Hospital, Bellinzona, Switzerland
| | - Ramon Pini
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Rolf Inderbitzi
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Stefano Cafarotti
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
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McGrath E, Ranstrom L, Lajoie D, McGlynn L, Mooney D. Is a Chest Radiograph Required After Removal of Chest Tubes in Children? J Pediatr Health Care 2017. [PMID: 28624231 DOI: 10.1016/j.pedhc.2017.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Our objective was to determine the clinical value of obtaining a chest radiograph after removal of a chest tube. We conducted a retrospective chart review of pediatric general surgical patients with a chest tube in place after a thoracic procedure over a 3-year time period. Postremoval films were considered to be of value if they led to a change in clinical management. Of 468 patients who had a thoracic procedure, 281 patients had a chest tube and a postremoval film. In 263 patients (93.6%) there was no change in the postremoval film result compared with baseline. Only two patients (0.7%) required an intervention based on symptoms, not based on the postremoval film. Eliminating routine postremoval radiographs after chest tube removal in pediatric patients will lessen radiation exposure and provide cost savings with no adverse impact on outcome.
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Poola AS, Rentea RM, Weaver KL, St Peter SD. Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility. Pediatr Surg Int 2017; 33:619-622. [PMID: 28260191 DOI: 10.1007/s00383-017-4057-8] [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] [Accepted: 01/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND While there is literature on techniques for pectus bar removal, there are limited reports on post-operative management. This can include obtaining a postoperative chest radiograph (CXR) despite the minimal risk of associated intra-thoracic complications. This is a review of our experience with bar removal and lack of routine post-operative CXR. METHODS A single institution retrospective chart review was performed from 2000 to 2015. Patients who underwent a pectus bar removal procedure were included. We assessed operative timing of bar placement and removal, procedure length, intra-operative and post-operative complications and post-operative CXR findings, specifically the rate of pneumothoraces. RESULTS 450 patients were identified in this study. Median duration of bar placement prior to removal was 35 months (interquartile range 30 and 36 months). Sixtey-four patients obtained a post-operative CXR. Of these, only one (58%) film revealed a pneumothorax; this was not drained. A CXR was not obtained in 386 (86%) patients with no immediate or delayed complications from this practice. Median follow-up time for all patients was 11 months (interquartile range 7.5-17 months). DISCUSSION The risk for a clinically relevant pneumothorax is minimal following bar removal. This suggests that not obtaining routine imaging following bar removal may be a safe practice.
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Affiliation(s)
- Ashwini Suresh Poola
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Katrina L Weaver
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Shawn David St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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Abstract
Portable chest radiography is a fundamental and frequently utilized examination in the critically ill patient population. The chest radiograph often represents a timely investigation of new or rapidly evolving clinical findings and an evaluation of proper positioning of support tubes and catheters. Thoughtful consideration of the use of this simple yet valuable resource is crucial as medical cost containment becomes even more mandatory. This review addresses the role of chest radiography in the intensive care unit on the basis of the existing literature and as formed by a consensus of an expert panel on thoracic imaging through the American College of Radiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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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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Leuzzi G, Facciolo F, Pastorino U, Rocco G. Methods for the postoperative management of the thoracic oncology patients: lessons from the clinic. Expert Rev Respir Med 2015; 9:751-67. [DOI: 10.1586/17476348.2015.1109453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Routinely obtained chest X-rays after elective video-assisted thoracoscopic surgery can be omitted in most patients; a retrospective, observational study. Gen Thorac Cardiovasc Surg 2015; 63:465-71. [PMID: 26007694 DOI: 10.1007/s11748-015-0560-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate whether the use of routinely obtained chest X-rays is necessary after elective VATS. METHODS We retrospectively reviewed 1097 chest X-rays obtained routinely after elective VATS, performed in patients aged over 15 years during an 18-month period. VATS procedures were divided into three groups according to the degree of pulmonary resection. The chest X-rays (obtained anterior-posterior in one plane with the patient in the supine position) were categorized as abnormal if showing pneumothorax >5 cm, possible intra-thoracic bleeding and/or a displaced chest tube. Medical charts were reviewed for all patients with abnormal chest X-rays to see if an intervention was made based on the X-ray. In case of an intervention, detailed clinical data were collected. RESULTS 44 of 1097 chest X-rays (4.0 %) were abnormal and 10 of these X-rays (0.9 %) led to a clinical intervention. Proportions of abnormal chest X-rays were unequally distributed between groups (p < 0.001), whereas the number of interventions was not (p = 0.43). Of the ten chests X-rays that led to an intervention, three showed possible intra-thoracic bleeding, six showed pneumothorax >5 cm and one showed a kinked chest tube. All the patients with possible intra-thoracic bleeding were re-explored in the operating theatre the same day. CONCLUSIONS Only 10 of 1097 chest X-rays (0.9 %) obtained routinely after elective VATS procedures led to a clinical intervention, supporting the abandon of routine chest X rays in favour of a more individualised approach, based on clinical observations.
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Affiliation(s)
- Lars S Bjerregaard
- Department of Cardiothoracic Anaesthesia and Section for Surgical Pathophysiology, Rigshospitalet Dept. 7621, Copenhagen University Hospital, Copenhagen, Denmark,
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Gelesko S, Wahlstrom D, Engelstad M. Routine Screening Radiography for Retained Wire Following Arch Bar Removal Is Not Indicated. J Oral Maxillofac Surg 2015; 74:796.e1-4. [PMID: 25936941 DOI: 10.1016/j.joms.2015.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 03/31/2015] [Accepted: 03/31/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE To estimate the screening test value of routine radiography after arch bar wire removal by assessing the incidence of retained wires and the importance of their sequelae. MATERIALS AND METHODS This was a retrospective medical record review. Records of arch bar removal procedures were examined and divided into those screened with radiography after removal (screen group) and those that were not screened (comparison group). The incidence of retained wire was calculated for each group. Study variables included wire-related radiographic or clinical findings. RESULTS Records of 546 mandible fractures were reviewed; 95 met the study criteria. Most exclusions were due to lack of arch bars, missing postoperative radiographs, or insufficient postoperative documentation. Of the 55 records in the screen group, 1 wire was detected (2%); of the 40 records in the comparison group, 1 wire was detected (3%). The total incidence of retained wire findings was not statistically different between the 2 groups and there were no adverse wire-related sequelae reported by any of the 95 patients. CONCLUSION Because of the low incidence of retained wires and wire-related sequelae, routine imaging after wire removal is probably not an effective screening test for retained wire and should be limited to situations in which there is clinical suspicion of retained wire.
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Affiliation(s)
- Savannah Gelesko
- Resident, Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR
| | - Devin Wahlstrom
- Dental Student, School of Dentistry, Oregon Health & Science University, Portland, OR
| | - Mark Engelstad
- Associate Professor, Departments of Oral and Maxillofacial Surgery and Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR.
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Defining indications for selective chest radiography in the first 24 hours after cardiac surgery. J Thorac Cardiovasc Surg 2015; 150:225-9. [PMID: 26005059 DOI: 10.1016/j.jtcvs.2015.04.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/06/2015] [Accepted: 04/11/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE In the intensive-care unit (ICU), chest radiographs (CXRs) are frequently obtained routinely for postoperative cardiac surgery patients, despite the fact that the efficacy of routine CXRs is known to be low. We investigated the efficacy and safety of CXRs performed after cardiac surgery for specified indications only. METHODS In this observational cohort study, we prospectively included all patients who underwent conventional major cardiac surgery by median sternotomy in the year 2012. On-demand CXRs could be obtained during the first postoperative period for specified indications only. A routine control CXR was performed on the morning of the first postoperative day for all patients who had not undergone a CXR before that time. The diagnostic and therapeutic efficacy values were calculated for all CXRs. Differences were tested using Fisher's exact test or χ(2) analysis. RESULTS A total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event. CONCLUSIONS Defining clear indications for selective CXRs after cardiac surgery is effective and seems to be safe. This approach may significantly reduce the total number of CXRs performed, and will increase their efficacy.
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What is the yield of routine chest radiography following tube thoracostomy for trauma? Injury 2015; 46:45-8. [PMID: 25062601 DOI: 10.1016/j.injury.2014.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 06/02/2014] [Accepted: 06/14/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Routine chest radiography (CXR) following tube thoracostomy (TT) is a standard practice in most trauma centres worldwide. Evidence supporting this routine practice is lacking and the actual yield is unknown. MATERIALS AND METHODS We performed a retrospective review of 1042 patients over a 4-year period who had a routine post-insertion CXR performed in accordance with current ATLS® recommendations. RESULTS A total 1042 TTs were performed on 1004 patients. Ninety-one per cent of patients (913/1004) were males, and the median age for all patients was 24 years. Seventy-five per cent of all injuries (756/1004) were from penetrating trauma, and the remaining 25% (248/1004) were from blunt. The initial pathologies requiring TT were: haemopneumothorax: 34% (339/1042), haemothroax: 31% (314/1042), simple pneumothorax: 25% (256/1042), tension pneumothorax: 8% (77/1042) and open pneumothorax: 5% (54/1042). One hundred and three patients had TTs performed on clinical grounds alone without a pre-insertion CXR [Group A]. One hundred and ninety-one patients had a pre-insertion CXR but had persistent clinical concerns following insertion [Group B]. Seven hundred and ten patients had pre-insertion CXR but no clinical concerns following insertion [Group C]. Overall, 15% (152/1004) [9 from Group A, 111 from Group B and 32 from Group C] of all patients had their clinical management influenced as a direct result of the post-insertion CXR. CONCLUSIONS Despite the widely accepted practice of routine CXR following tube thoracostomy, the yield is relatively low. In many cases, good clinical examination post tube insertion will provide warnings as to whether problems are likely to result. However, in the more rural setting, and in resource challenged environments, there is a relatively high yield from the CXR, which alters management. Further prospective studies are needed to establish or refute the role of the existing ATLS® guidelines in these specific environments.
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Tolsma M, Bentala M, Rosseel PMJ, Gerritse BM, Dijkstra HAJ, Mulder PGH, van der Meer NJM. The value of routine chest radiographs after minimally invasive cardiac surgery: an observational cohort study. J Cardiothorac Surg 2014; 9:174. [PMID: 25385274 PMCID: PMC4232684 DOI: 10.1186/s13019-014-0174-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 10/21/2014] [Indexed: 11/10/2022] Open
Abstract
Background Chest radiographs (CXRs) are obtained frequently in postoperative cardiac surgery patients. The diagnostic and therapeutic efficacy of routine CXRs is known to be low and the discussion regarding the safety of abandoning these CXRs after cardiac surgery is still ongoing. We investigated the value of routine CXRs directly after minimally invasive cardiac surgery. Methods We prospectively included all patients who underwent minimally invasive cardiac surgery by port access, ministernotomy or bilateral video-assisted thoracoscopy (VATS) in the year 2012. A direct postoperative CXR was performed on all patients at ICU arrival. All CXR findings were noted, including whether they led to an intervention or not. The results were compared to the postoperative CXR results in patients who underwent conventional cardiac surgery by full median sternotomy over the same period. Main results A total of 249 consecutive patients were included. Most of these patients underwent valve surgery, rhythm surgery or a combination of both. The diagnostic efficacy for minor findings was highest in the port access and bilateral VATS groups (56% and 63% versus 28% and 45%) (p < 0.005). The diagnostic efficacy for major findings was also higher in these groups (8.9% and 11% versus 4.3% and 3.8%) (p = 0.010). The need for an intervention was most common after minimally invasive surgery by port access, although this difference was not statistically significant (p = 0.056). Conclusions The diagnostic efficacy of routine CXRs performed after minimally invasive cardiac surgery by port access or bilateral VATS is higher than the efficacy of CXRs performed after conventional cardiac surgery. A routine CXR after these procedures should still be considered.
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Affiliation(s)
- Martijn Tolsma
- Department of Anesthesiology & Intensive Care, Isala Klinieken, Dokter van Heesweg 2, 8025, AB, Zwolle, The Netherlands.
| | - Mohamed Bentala
- Department of Cardiothoracic Surgery, Amphia Hospital, Molengracht 21, 4818, CK, Breda, The Netherlands.
| | - Peter M J Rosseel
- Department of Anesthesiology & Intensive Care, Amphia Hospital, Molengracht 21, 4818, CK, Breda, The Netherlands.
| | - Bastiaan M Gerritse
- Department of Anesthesiology & Intensive Care, Amphia Hospital, Molengracht 21, 4818, CK, Breda, The Netherlands.
| | - Homme A J Dijkstra
- Department of Radiology, Amphia Hospital, Molengracht 21, 4818, CK, Breda, The Netherlands.
| | - Paul G H Mulder
- Amphia Hospital, Amphia Academy, Molengracht 21, 4818, CK, Breda, The Netherlands.
| | - Nardo J M van der Meer
- Department of Anesthesiology & Intensive Care, Amphia Hospital, Molengracht 21, 4818, CK, Breda, The Netherlands. .,TiasNimbas Business School, Tilburg University, Warandelaan 2, 5037, AB, Tilburg, The Netherlands.
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Cunningham JP, Knott EM, Gasior AC, Juang D, Snyder CL, St Peter SD, Ostlie DJ. Is routine chest radiograph necessary after chest tube removal? J Pediatr Surg 2014; 49:1493-5. [PMID: 25280653 DOI: 10.1016/j.jpedsurg.2014.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/07/2014] [Accepted: 01/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR. METHODS After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction. RESULTS 462 patients were identified (group 1=327, group 2=135). Indications for CT included; empyema (n=176), lung resection (n=146), pneumothorax (n=71), pleural effusion (n=26), spinal fusion (n=20), trauma (n=16), and miscellaneous (n=7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n=4), empyema (n=2), and pleural effusion (n=1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P=0.2). CONCLUSIONS In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.
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Affiliation(s)
| | | | | | - David Juang
- The Children's Mercy Hospital, Kansas City, MO
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Tolsma M, Rijpstra TA, Schultz MJ, Mulder PG, van der Meer NJ. Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey. Ann Intensive Care 2014; 4:10. [PMID: 24708581 PMCID: PMC4113284 DOI: 10.1186/2110-5820-4-10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 03/24/2014] [Indexed: 11/10/2022] Open
Abstract
Background ICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments. Methods Web-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013. Results Of the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of ‘on-demand’ CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization. Conclusion The strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.
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Affiliation(s)
- Martijn Tolsma
- Department of Intensive Care, University Medical Center, Postbus 85500, 3508 GA Utrecht, The Netherlands.
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Gelesko S, Markiewicz MR, Bell RB. Responsible and Prudent Imaging in the Diagnosis and Management of Facial Fractures. Oral Maxillofac Surg Clin North Am 2013; 25:545-60. [DOI: 10.1016/j.coms.2013.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Reeb J, Falcoz PE, Olland A, Massard G. Are daily routine chest radiographs necessary after pulmonary surgery in adult patients? Interact Cardiovasc Thorac Surg 2013; 17:995-8. [PMID: 23956264 DOI: 10.1093/icvts/ivt352] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic was constructed according to a structured protocol. The question addressed was whether daily routine (DR) chest radiographs (CXRs) are necessary after pulmonary surgery in adult patients. Of the 66 papers found using a report search, seven presented the best evidence to answer the clinical question. Four of these seven studies specifically addressed post-cardiothoracic adult patients. Three of these seven studies addressed intensive care unit (ICU) patients and included post-cardiothoracic adult patients in well-designed studies. Six of these seven studies compared the DR CXRs strategy to the clinically indicated, on-demand (OD) CXRs strategy. Another study analysed the clinical impact of ceasing to perform the DR, postoperative, post-chest tubes removal CXRs. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that, on the whole, the seven studies are unanimously in favour of forgoing DR CXRs after lung resection and advocate OD CXRs. One study suggested that hypoxic patients could benefit from a DR CXRs strategy, while other studies failed to identify any subgroup for whom performing DR CXRs was beneficial. Indeed, DR CXRs, commonly taken after thoracic surgery, have poor diagnostic and therapeutic value. Eliminating them for adult patients having undergone thoracic surgery significantly decreases the number of CXRs per patient without increasing mortality rates, length of hospital stays (LOSs), readmission rates and adverse events. Hence, current evidence shows that DR CXRs could be forgone after lung resection because OD CXRs, recommended by clinical monitoring, have a better impact on management and have not been proved to negatively affect patient outcomes. Moreover, an OD CXRs strategy lowers the cost of care. Nevertheless, an OD CXRs strategy requires close clinical monitoring by experienced surgeons and dedicated intensivists. However, given the published studies' low level of evidence, prospective and randomized trials, specifically after thoracic surgery, are necessary in order to confirm these results.
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Affiliation(s)
- Jeremie Reeb
- Department of Thoracic Surgery, University Hospital, Strasbourg, France
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Biegler N, McBeth PB, Tiruta C, Hamilton DR, Xiao Z, Crawford I, Tevez-Molina M, Miletic N, Ball CG, Pian L, Kirkpatrick AW. The feasibility of nurse practitioner-performed, telementored lung telesonography with remote physician guidance - 'a remote virtual mentor'. Crit Ultrasound J 2013; 5:5. [PMID: 23805869 PMCID: PMC3735420 DOI: 10.1186/2036-7902-5-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 06/12/2013] [Indexed: 01/01/2023] Open
Abstract
Background Point-of-care ultrasound (POC-US) use is increasingly common as equipment costs decrease and availability increases. Despite the utility of POC-US in trained hands, there are many situations wherein patients could benefit from the added safety of POC-US guidance, yet trained users are unavailable. We therefore hypothesized that currently available and economic ‘off-the-shelf’ technologies could facilitate remote mentoring of a nurse practitioner (NP) to assess for recurrent pneumothoraces (PTXs) after chest tube removal. Methods The simple remote telementored ultrasound system consisted of a handheld ultrasound machine, head-mounted video camera, microphone, and software on a laptop computer. The video output of the handheld ultrasound machine and a macroscopic view of the NP's hands were displayed to a remote trauma surgeon mentor. The mentor instructed the NP on probe position and US machine settings and provided real-time guidance and image interpretation via encrypted video conferencing software using an Internet service provider. Thirteen pleural exams after chest tube removal were conducted. Results Thirteen patients (26 lung fields) were examined. The remote exam was possible in all cases with good connectivity including one trans-Atlantic interpretation. Compared to the subsequent upright chest radiograph, there were 4 true-positive remotely diagnosed PTXs, 2 false-negative diagnoses, and 20 true-negative diagnoses for 66% sensitivity, 100% specificity, and 92% accuracy for remotely guided chest examination. Conclusions Remotely guiding a NP to perform thoracic ultrasound examinations after tube thoracostomy removal can be simply and effectively performed over encrypted commercial software using low-cost hardware. As informatics constantly improves, mentored remote examinations may further empower clinical care providers in austere settings.
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Affiliation(s)
- Nancy Biegler
- Regional Trauma Services, Foothills Medical Centre, Calgary, Alberta T2N 2T9, Canada.
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Woodward CS, Dowling D, Taylor RP, Savin C. The routine use of chest radiographs after chest tube removal in children who have had cardiac surgery. J Pediatr Health Care 2013; 27:189-94. [PMID: 22178721 DOI: 10.1016/j.pedhc.2011.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 08/23/2011] [Accepted: 09/02/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND It is routine to obtain a chest radiograph (CXR) after removal of a chest tube (CT) to assess for pneumothorax. Retrospective studies have shown that clinical signs were present in most children with pneumothorax and were an indication for a CXR. OBJECTIVE Our objective was to determine if clinical indicators of pneumothorax are sufficient predictors of the need for CT reinsertion in children who have had a CT removed after cardiac surgery. METHODS The prospective study included a physical assessment before CT removal, using a two-person technique, which was repeated 2 hours after CT removal. Based on assessment findings, a decision was made regarding whether a CXR was indicated. The routine CXR was then obtained and read by a pediatric intensivist who was blinded to the decision of the investigator. RESULTS Sixty CTs were removed in 53 children. No false-positive predictions were made, because none of the children was predicted to have a pneumothorax requiring chest tube reinsertion, and none developed a significant pneumothorax (95% confidence interval: 0, 5%). CONCLUSIONS The low rate of pneumothoraces in this study may be been related to how the CT was placed in surgery, the type of CT used, or the method of removal. In this study the risk of developing a pneumothorax requiring CT reinsertion after CT removal was at most 5% and therefore low enough to consider obtaining a CXR for symptomatic children only.
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Affiliation(s)
- Cathy S Woodward
- Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX, USA.
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Sepehripour AH, Farid S, Shah R. Is routine chest radiography indicated following chest drain removal after cardiothoracic surgery? Interact Cardiovasc Thorac Surg 2012; 14:834-8. [PMID: 22392935 DOI: 10.1093/icvts/ivs037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was whether routine chest radiography is indicated following chest drain removal in patients undergoing cardiothoracic surgery. A total of 356 papers were found using the reported searches; of which, 6 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were mean duration of drains left in situ, timing of drain removal, pathology detected on chest radiographs (CXRs), interventions following imaging and clinical assessment, complications in patients not undergoing routine CXRs and the cost saving of omitting routine CXRs. One large cohort study reported the detection of pathology in 79% of clinically indicated CXRs in comparison to 40% of routine CXRs (P = 0.005). Ninety-five per cent of the non-routine CXR cohort remained asymptomatic and required no intervention. One large observational study reported the detection of new pneumothoraces in 9.3% of patients, 70.3% of which were barely perceptible. Intervention following CXR was required in 0.25% and only one medium-sized pneumothorax would have been potentially missed without CXR. Another large observational study reported intervention following CXR in 1.9% and the presence of relevant clinical signs and symptoms to be a significant predictor of major intervention (P < 0.01). A smaller observational study reported no pathology detected or intervention following CXR in 98% and the cost saving of omitting a single CXR at £10 000 per annum. Another small observational study reported only 7% of CXRs to be clinically indicated with a false-positive rate of 100%, and a false-negative rate of 7% in CXRs not clinically indicated. The smallest study reported no complications in the non-CXR cohort and only one patient undergoing intervention in the routine CXR cohort. We conclude that there is evidence that routine post drain removal CXR provides no diagnostic or therapeutic advantage over clinically indicated CXR or simple clinical assessment. The best evidence studies reported the detection of pathology on routine CXR ranging from 2 to 40% compared with 79% in clinically indicated CXRs (P = 0.005). Whilst the rate of intervention following routine CXR was as high as 4% in the smallest study, clinical signs and symptoms suggestive of pathology were a significant predictor of major re-intervention (P < 0.01).
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Affiliation(s)
- Amir H Sepehripour
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK.
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