Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection?-A prospective randomized trial

The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains After Pulmonary Lobectomy: Expert Consensus Document

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.

Clinical significance of postoperative thrombocytosis after vats lobectomy for NSCLC

OBJECTIVES

Thrombocytosis is a clinical condition generally associated with poor prognosis in patients with cancer. Thrombocytosis may be present after lung cancer resection, but the clinical significance of thrombocytosis remains unclear. Herein, we evaluated whether postoperative thrombocytosis was a negative prognostic factor in patients undergoing thoracoscopic lobectomy for lung cancer.

METHODS

It was a retrospective monocentric study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer from January 2020 to January 2023. The outcome of patients with postoperative thrombocytosis (defined as platelet count ≥ 450 × 10^9/L at 24 h after the surgery and confirmed at postoperative day 7) was compared with a control group. Postoperative morbidity, mortality, and survival were compared between the two groups to define whether thrombocytosis negatively affected outcomes.

RESULTS

Our study population included 183 patients; of these, 22 (12%) presented postoperative thrombocytosis: 9 (5%) mild thrombocytosis (451-700 × 10^9/L), 10 (5%) moderate thrombocytosis (701-900 × 10^9/L), and 3 (2%) severe thrombocytosis (901-1000 × 10^9/L). No significant differences were found regarding postoperative morbidity (p = 0.92), mortality (p = 0.53), overall survival (p = 0.45), and disease-free survival (p = 0.60) between the two study groups. Thrombocytosis was associated with higher rate of atelectasis (36% vs. 6%, p < 0.001) and residual pleural effusion (31% vs. 8%, p = 0.0008). Thrombocytosis group was administered low-dose acetylsalicylic acid for 10 days and no thrombotic events were observed. In all cases the platelet count returned to be within normal value at postoperative day 30.

CONCLUSIONS

Postoperative thrombocytosis seems to be a transient condition due to an inflammatory state and it does not affect the surgical outcome and survival after thoracoscopic lobectomy.

Postoperative management using a digital drainage system for massive air leakage after pulmonary resection

PURPOSE

To elucidate clinical outcomes using a digital drainage system (DDS) for massive air leakage (MAL) after pulmonary resection.

METHODS

A total of 135 consecutive patients with pulmonary resection air leakage of > 100 ml/min on the DDS were evaluated retrospectively. In this study, MAL was defined as ≥ 1000 ml/min on the DDS. We analyzed the clinical characteristics and surgical outcomes of patients with MAL compared with non-MAL (101-999 ml/min). Using the DDS data, the duration of the air leak was plotted with the Kaplan‒Meier method and compared using the log-rank test.

RESULTS

MAL was detected in 19 (14%) patients. The proportions of heavy smokers (P = 0.04) and patients with emphysematous lung (P = 0.03) and interstitial lung disease (P < 0.01) were higher in the MAL group than in the non-MAL group. The MAL group had a higher persistence rate of air leakage at 120 h after surgery than the non-MAL group (P < 0.01) and required significantly more frequent pleurodesis (P < 0.01). Drainage failure occurred in 2 (11%) and 5 (4%) patients from the MAL and non-MAL groups, respectively. Neither reoperation nor 30-day surgical mortality was observed in patients with MAL.

CONCLUSIONS

MAL was able to be treated conservatively without surgery using the DDS.

Use of a Digital Air Leak Detection Device to Decrease Chest Tube Duration

BACKGROUND

The aim of this evidence-based practice project was to determine if a digital air leak detection device could speed the identification of chest tube air leak cessation in patients after pulmonary lobectomy. Staff members assessing air leaks have varying levels of expertise, and the digital device is a limited resource in the study institution. A chest tube management algorithm is necessary to standardize care and determine which patients are most likely to benefit.

IMPLEMENTATION

Twenty-five consecutive patients who underwent pulmonary lobectomy during the study period and continued to have a chest tube air leak on postoperative day 3 were monitored with digital air leak detection devices. The Mann-Whitney U test was used to compare chest tube duration and hospital length of stay between patients with digital devices and 259 patients who had traditional analog air leak detection devices (historical data from the departmental database over the previous 2 years).

EVALUATION

Median chest tube duration and hospital stay were 1 day less in patients with digital devices than in those with traditional analog devices (P = .01 and P = .004, respectively), with a cost savings of $2659 per hospital day. Reductions in chest tube duration and length of stay aided in the development of a chest tube management algorithm.

CONCLUSIONS

Critical care nurses are valued team members who treat patients after lung resections. Digital air leak detection devices can help them assess air leaks more accurately, benefiting the patients in their care.

Comparison Between Electronic and Traditional Chest Drainage Systems: A Multicenter Randomized Study

BACKGROUND

Air leak is the major factor that influences the permanence of the chest tube and the in-hospital length of stay (LOS) among patients undergoing lung resections. The aim of this study was to determine whether the use of digital chest drain systems, compared with traditional ones, reduced the duration of chest drainage and postoperative in-hospital LOS in patients undergoing video-assisted thoracoscopic (VATS) lobectomy.

METHODS

The study was a prospective, randomized, multicenter trial. Patients undergoing VATS lobectomy were randomized in 2 groups, receiving a digital drain system or a traditional one and managed accordingly to the protocol.

RESULTS

Among 503 patients who fulfilled inclusion criteria and were randomized, 38 dropped out after randomization. Finally, 465 patients were analyzed, of whom 204 used the digital device and 261 the traditional one. In the digital group, there was a significantly shorter median chest tube duration of 3 postoperative days (interquartile range [IQR], 2-4 days) vs 4 postoperative days (IQR, 3-4 days; P = .001) and postoperative in-hospital LOS of 4 days (IQR, 3-6 days) vs 5 days (IQR, 4-6 days; P = .035). Analysis of predictors for increased duration of air leaks showed a relationship with male sex (P = .039), forced expiratory volume in 1 second percentage (P = .004), forced vital capacity percentage (P = .03), and presence of air leaks at the end of surgery (P = .001).

CONCLUSIONS

In patients undergoing VATS lobectomy, the use of a digital drainage system allows an earlier removal of the chest drain compared with the traditional system, leading to a shorter in-hospital LOS.

Advantages of applying digital chest drainage system for postoperative management of patients following pulmonary resection: a systematic review and meta-analysis of 12 randomized controlled trials

OBJECTIVES

This meta-analysis aimed to evaluate the value of the chest digital drainage system for the postoperative management of patients who have undergone pulmonary resection.

METHODS

We searched the PubMed, EMBASE, the Cochrane Library, and Web of Science databases for included randomized controlled trials (RCTs) on the application of digital drainage systems versus the analog drainage system for patients with lung disease after pulmonary resection. Dichotomous variables were evaluated using risk ratios (RRs) and 95% confidence intervals (CIs), and mean and standardized mean differences (MDs and SMDs, respectively) with 95% CIs were used to calculate continuous variables. Statistical analyses were performed using Stata and RevMan software.

RESULTS

In total, 12 RCTs involving 2000 patients were analyzed. Significant differences in duration of chest tube placement (SMD =  -0.49; 95% CI =  -0.78 to -0.20), length of hospital stay (MD =-0.79 days; 95% CI = -1.24 to -0.34), and number of chest tube clamping tests (RR = 0.74; 95% CI = 0.36-1.49) were observed between the two groups, which did not significant differ in the occurrence of prolonged air leak or cardiopulmonary complication rate.

CONCLUSIONS

The digital chest drainage system is mainly advantageous in the duration of chest tube placement, length of hospital stay, and number of chest tube clamping tests. Future research should evaluate the requirements and economic impact of using digital system in routine clinical practice.

Promising Effects of Digital Chest Tube Drainage System for Pulmonary Resection: A Systematic Review and Network Meta-Analysis

Objective: The chest tube drainage system (CTDS) of choice for the pleural cavity after pulmonary resection remains controversial. This systematic review and network meta-analysis (NMA) aimed to assess the length of hospital stay, chest tube placement duration, and prolonged air leak among different types of CTDS. Methods: This systemic review and NMA included 21 randomized controlled trials (3399 patients) in PubMed and Embase until 1 June 2021. We performed a frequentist random effect in our NMA, and a P-score was adopted to determine the best treatment. We assessed the clinical efficacy of different CTDSs (digital/suction/non-suction) using the length of hospital stay, chest tube placement duration, and presence of prolonged air leak. Results: Based on the NMA, digital CTDS was the most beneficial intervention for the length of hospital stay, being 1.4 days less than that of suction CTDS (mean difference (MD): −1.40; 95% confidence interval (CI): −2.20 to −0.60). Digital CTDS also had significantly reduced chest tube placement duration, being 0.68 days less than that of suction CTDSs (MD: −0.68; 95% CI: −1.32 to −0.04). Neither digital nor non-suction CTDS significantly reduced the risk of prolonged air leak. Conclusions: Digital CTDS is associated with better outcomes than suction and non-suction CTDS for patients undergoing pulmonary resections, specifically 0.68 days shorter chest tube duration and 1.4 days shorter hospital stay than suction CTDS.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Use of thopaz in patients of empyema thoracis undergoing decortication

Introduction:

The management of empyema thoracis has evolved over the years. After all lung surgeries chest drain is required, however they suffer from inter observer variability and impair mobility of the patient. However, the newer digital thoracic drain system are portable and have alarms for various situations, furthermore they eliminate inter-observer variability. One such device is Thopaz™ (Medela inc, Switzerland). We wanted to compare efficacy of Thopaz™ with our conventional intercostal chest tube drain in patients undergoing decortications for empyema thoracis.

Materials and Methods:

One hundred patients were enrolled in study and were randomized into conventional and thopaz group with 50 patients in each group with help of opaque envelopes.

Results:

Both the groups were comparable in demographic parameters. Majority of the patients in our study were children and young adults. Majority of empyema thoracis involved right side with nontubercular empyema thoracis being the most common cause of decorticartion. Patients managed with Thopaz had a significantly shorter air leak duration, shorter duration of postdecortication chest tube placement and shorter postoperative hospital stay. All postoperative complications were less in Thopaz group.

Conclusions:

Patients with empyema thoracis undergoing open decortications when managed with digital chest drainage system (Thopaz) experienced faster reduction in air leak, a shorter duration of chest tube placement and in hospital stay. Thopaz usage is also associated with reduction in rate of postoperative complications. We recommend that this digital chest tube drainage system is a very useful tool in armamentarium of thoracic surgeon after lung surgeries.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Feasibility of autologous fibrin glue in general thoracic surgery

Background

Fibrin glue effectively controls air leakage in lung surgery; however, allogenic fibrin glue cannot eliminate the risks of infection and allergy despite current sterilization methods. Autologous fibrin glue (AFG) could be a good alternative, but is not commonly used worldwide because of its limited availability and lack of evidence. Herein, we report clinical outcomes of AFG in thoracic surgery.

Methods

We retrospectively analyzed patients who underwent lobectomies or segmentectomies between November 2016 and September 2017 in our institution. We used two types of AFGs. One was a partially-autologous fibrin glue (PAFG), the components of which are largely autologous but which contains allogenic thrombin. The other was a completely-autologous fibrin glue (CAFG) which has no allogenic components. PAFG was used in the first half of the study period, after which CAFG was used from March 2017 onward. Patients who did not undergo AFG generation were categorized as the non-AFG group. The perioperative outcomes of the three groups were evaluated.

Results

A total of 207 patients underwent lung surgery, including 118 lobectomies and 89 segmentectomies. Among them, 83 patients received PAFG, 94 received CAFG, and 30 received non-AFG. The mean postoperative drainage period was within a few days in each group (PAFG vs. CAFG vs. non-AFG: 3.23±3.91 vs. 3.16±4.04 vs. 3.17±4.16 days, respectively; P=0.405), and the incidence of postoperative prolonged air leakage was within an acceptable range (PAFG vs. CAFG vs. non-AFG: 13.3% vs. 12.8% vs. 16.7%, respectively; P=0.821).

Conclusions

The use of AFG is clinically feasible for patients who undergo lobectomies or segmentectomies. AFGs could be a viable alternative to conventional allogenic fibrin glues.

A Systematic Review of Digital vs Analog Drainage for Air Leak After Surgical Resection or Spontaneous Pneumothorax

BACKGROUND

The concerns regarding air leak after lung surgery or spontaneous pneumothorax include detection and duration. Prior studies have suggested that digital drainage systems permit shorter chest tube duration and hospital length of stay (LOS) by earlier detection of air leak cessation. We conducted a systematic review to assess the impact of digital drainage on chest tube duration and hospital LOS after pulmonary surgery and spontaneous pneumothorax.

METHODS

Ovid MEDLINE, PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar were searched from inception through January 2019. We included randomized controlled trials, cohort studies, and case series of adult patients, using digital or traditional drainage devices for air leaks of either postsurgical or spontaneous pneumothorax origin.

RESULTS

Of 1,272 references reviewed, 23 articles were included. Nineteen articles addressed postoperative air leak, and four articles pertained to air leak after spontaneous pneumothorax. Thirteen studies were randomized controlled trials. Digital drainage resulted in significantly shorter chest tube duration in eight of 18 studies and shorter hospital LOS in six of 14 studies for postoperative air leak. For postpneumothorax air leak, digital drainage resulted in significantly shorter chest tube duration in two of three studies and hospital LOS in one of two studies with an analog control group.

CONCLUSIONS

Most studies show no significant differences in chest tube duration and hospital LOS with digital vs analog drainage systems for patients with air leak after pulmonary resection. For post-spontaneous pneumothorax air leak, the limited published evidence suggests shorter chest tube duration and hospital LOS with digital drainage systems.

Digital chest drainage system versus traditional chest drainage system after pulmonary resection: a systematic review and meta-analysis

BACKGROUND

Several randomized controlled trials (RCTs) and observational studies have compared the efficacy of digital chest drainage system versus traditional chest drainage system. However, the results were inconsistent.

METHODS

We searched the Web of Science and Pubmed for observational studies and RCTs that compared the effect of digital chest drainage system with traditional chest drainage system after pulmonary resection. Eight studies (5 randomized control trails and 3 observational studies) comprising 1487 patients met the eligibility criteria.

RESULTS

Compared with the traditional chest drainage system, digital chest drainage system reduced the risk of prolonged air leak (PAL) (RR = 0.54, 95%CI 0.40-0.73, p < 0.0001), and shortened the duration of chest drainage (SMD = - 0.35, 95%CI -0.60 - -0.09, p = 0.008) and length of hospital stay (SMD = - 0.35, 95%CI -0.61 - -0.09, p = 0.007) in patients after pulmonary resection.

CONCLUSIONS

Digital chest drainage system is expected to benefit patients to attain faster recovery and higher life quality as well as to reduce the risk of postoperative complications. Further RCTs with larger sample size are still needed to more clearly elucidate the advantages of digital chest drainage system.