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The benefits of digital chest drainage in pleural decortication in thoracic empyema. Prospective, randomised, control trial

Authors:
  • Hospitales Angeles. Minimal Invasive Thoracic Surgery Institute.

Abstract and Figures

Background Prolonged air leak after pleural decortication is one of the most frequent complications. Objective The aim of this study is to compare the effects of prolonged air leak between the digital chest drainage (DCD) system and the classic drainage system in patients with empyema class IIB or III (American Thoracic Society classification) in pleural decortication patients. Material and methods A total of 37 patients were enrolled in a prospective randomised control trial over one year, consisting of 2 blinded groups, comparing prolonged air leak as a main outcome, the number of days until removal of chest drain, length of hospital stay and complications as secondary outcomes. Results The percentage of prolonged air leak was 11% in the DCD group and 5% in the classic group (p = 0.581); the mean number of days of air leak was 2.5±1.8 and 2.4±2.2, respectively (p = 0.966). The mean number of days until chest tube removal was 4.5±1.8 and 5.1±2.5 (p = 0.41), the length of hospital stay was 7.8±3.7 and 8.9±4.0 (p = 0.441) and the complication percentages were 4 (22%) and 7 (36%), respectively (p = 0.227). Discussion In this study, no significant difference was observed when the DCD was compared with the classic system. This was the first randomised clinical trial for this indication; thus, future complementing studies are warranted.
Content may be subject to copyright.
Cirugía
y
Cirujanos.
2017;85(6):522---525
www.amc.org.mx
www.elsevier.es/circir
CIRUGÍA
y
CIRUJANOS
Órgano
de
difusión
científica
de
la
Academia
Mexicana
de
Cirugía
Fundada
en
1933
ORIGINAL
ARTICLE
The
benefits
of
digital
chest
drainage
in
pleural
decortication
in
thoracic
empyema.
Prospective,
randomised,
control
trial
José
M.
Mier,
Gildardo
Cortés-Julián,
Juan
Berrios-Mejía,
Zotés
Víctor-Valdivia
Servicio
de
Cirugía
Cardiotorácica,
Instituto
Nacional
de
Enfermedades
Respiratorias
INER,
Ciudad
de
México,
Mexico
Received
3
November
2016;
accepted
26
November
2016
Available
online
7
February
2018
KEYWORDS
Digital
chest
drainage;
Prolonged
air
leak;
Decortication
Abstract
Background:
Prolonged
air
leak
after
pleural
decortication
is
one
of
the
most
frequent
complications.
Objective:
The
aim
of
this
study
is
to
compare
the
effects
of
prolonged
air
leak
between
the
digital
chest
drainage
(DCD)
system
and
the
classic
drainage
system
in
patients
with
empyema
class
IIB
or
III
(American
Thoracic
Society
classification)
in
pleural
decortication
patients.
Material
and
methods: A
total
of
37
patients
were
enrolled
in
a
prospective
randomised
control
trial
over
one
year,
consisting
of
2
blinded
groups,
comparing
prolonged
air
leak
as
a
main
out-
come,
the
number
of
days
until
removal
of
chest
drain,
length
of
hospital
stay
and
complications
as
secondary
outcomes.
Results:
The
percentage
of
prolonged
air
leak
was
11%
in
the
DCD
group
and
5%
in
the
classic
group
(p
=
0.581);
the
mean
number
of
days
of
air
leak
was
2.5±1.8
and
2.4±2.2,
respec-
tively
(p
=
0.966).
The
mean
number
of
days
until
chest
tube
removal
was
4.5±1.8
and
5.1±2.5
(p
=
0.41),
the
length
of
hospital
stay
was
7.8±3.7
and
8.9±4.0
(p
=
0.441)
and
the
complication
percentages
were
4
(22%)
and
7
(36%),
respectively
(p
=
0.227).
Discussion:
In
this
study,
no
significant
difference
was
observed
when
the
DCD
was
compared
with
the
classic
system.
This
was
the
first
randomised
clinical
trial
for
this
indication;
thus,
future
complementing
studies
are
warranted.
©
2016
Academia
Mexicana
de
Cirug´
ıa
A.C.
Published
by
Masson
Doyma
M´
exico
S.A.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-
nc-nd/4.0/).
PII
of
original
article:
S0009-7411(16)30128-1
Please
cite
this
article
as:
Mier
JM,
Cortés-Julián
G,
Berrios-Mejía
J,
Víctor-Valdivia
Z.
Beneficios
del
drenaje
torácico
digital
en
pleurodecorticación
por
empiema.
Estudio
prospectivo,
comparativo
aleatorizado.
Cir
Cir.
2017;85:522---525.
Corresponding
author
at:
Servicio
de
Cirugía
Cardiotorácica,
Instituto
Nacional
de
Enfermedades
Respiratorias
INER,
Calzada
de
Tlalpan
4502,
Col.
Secc.
XVI,
C.P.
14080,
Mexico
City,
Mexico.
Tel.:
+52
55
2107
8324.
E-mail
address:
jmmo50@hotmail.com
(J.M.
Mier).
2444-0507/©
2016
Academia
Mexicana
de
Cirug´
ıa
A.C.
Published
by
Masson
Doyma
M´
exico
S.A.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
The
benefits
of
digital
chest
drainage
in
thoracic
empyema
523
PALABRAS
CLAVE
Drenaje
torácico
digital;
Fuga
aérea
prolongada;
Decorticación
Beneficios
del
drenaje
torácico
digital
en
pleurodecorticación
por
empiema.
Estudio
prospectivo,
comparativo
aleatorizado
Resumen
Antecedentes:
La
fuga
aérea
prolongada
después
de
una
pleuro-decorticación
en
una
de
las
complicaciones
más
frecuentes.
Objetivo:
El
objetivo
de
este
estudio
es
comparar
la
fuga
aérea
entre
el
sistema
de
drenaje
torácico
digital
(DCD)
y
el
sistema
de
drenaje
clásico,
en
pacientes
con
empiema
de
clase
IIB
o
III
(clasificación
de
la
Sociedad
Americana
de
Tórax)
intervenidos
mediante
pleuro-decorticación.
Material
y
métodos:
De
manera
prospectiva,
comparativa
y
aleatorizada,
37
pacientes
fueron
estudiados
en
un
periodo
de
un
a˜
no.
Divididos
en
2
grupos,
se
comparó
la
fuga
aérea
postoper-
atoria,
analizándose
el
número
de
días
de
internamiento,
el
día
de
retiro
de
los
drenajes,
así
como
las
complicaciones
en
ambos
grupos.
Resultados:
El
porcentaje
de
fuga
aérea
prolongada
fue
del
11%
en
el
grupo
DCD
y
del
5%
en
el
grupo
de
drenaje
clásico
(p
=
0,581);
el
número
de
días
con
fuga
aérea
fue
de
2,5
±
1,8
y
2,4
±
2,2,
respectivamente
(p
=
0,966).
El
número
de
días
para
retiro
de
drenaje
fue
4,5
±
1,8
y
5,1
±
2,5
(p
=
0,41),
la
estancia
intrahospitalaria
fue
de
7,8
±
3,7
y
8,9
±
4
días
(p
=
0,441)
y
el
porcentaje
de
complicaciones
fue
22
y
36%,
respectivamente
(p
=
0,227).
Discusión:
En
este
estudio
se
observa
una
tendencia
positiva
pero
no
significativa
a
favor
del
uso
de
los
DCD
cuando
se
comparan
con
el
drenaje
clásico.
Estudios
más
largos
y
multicéntricos
son
requeridos.
©
2016
Academia
Mexicana
de
Cirug´
ıa
A.C.
Publicado
por
Masson
Doyma
M´
exico
S.A.
Este
es
un
art´
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Background
Empyema
is
one
of
the
most
common
surgical
chest
condi-
tions
in
Mexico.
A
great
many
of
these
patients
(45%)
require
surgical
treatment,
which
represents
around
90
cases
of
pleural
decortication.1
Air
leak
after
complete
decortication
is
to
be
expected,
and
even
more
so
in
advanced
empyema.2However,
digi-
tal
chest
drainage
(DCD)
digital
has
shown
good
results
in
the
management
of
prolonged
air
leak
in
various
surgical
procedures.3A
reduction
in
days
of
drainage
and
hospital
stay
has
been
demonstrated
with
these
drains.3 --- 7 Probably
one
of
their
greatest
advantages
is
the
elimination
of
inter-
observer
variability
on
assessing
air
leak
for
removal
of
the
drains.7,8 The
DCD
system
has
even
been
used
in
ambulant
patients
with
prolonged
air
leak.7,9
DCD
use
in
pleural
decortication
has
not
been
described
in
the
literature.
Therefore,
the
aim
of
our
study
was
to
evaluate
its
potential
benefits,
which
will
be
valuable
infor-
mation
for
surgeons,
since
this
technology
is
increasingly
available
in
chest
surgery
departments.
Material
and
methods
A
prospective,
comparative
and
randomised
study
of
37
patients
treated
with
pleural
decortication
due
to
empyema
classified
as
IIB
or
III
by
the
American
Thoracic
Society,
in
the
period
from
March
2013
to
February
2014.
The
sample
size
was
calculated
according
to
the
published
data.7The
statis-
tical
power
was
set
at
5%
and
the
beta
error
at
80%,
with
a
minimum
of
16
patients
per
group.
The
DCD
group
had
18
patients,
and
there
were
17
in
the
traditional
group.
The
patients
included
in
the
study
had
IIB
or
III
empyema,
which
had
not
been
resolved
by
the
placement
of
a
drain.
Patients
with
other
grades
of
empyema,
those
who
under-
went
thoracoscopic
surgery,
and
those
with
a
physical
status
classification
greater
than
ASA
III
prior
to
anaesthesia
were
excluded.
The
Thopaz-MedelaTM (Switzerland)
system
was
used
for
the
DCD
group;
traditional
Atrium
OceanTM drains
were
used
(U.S.A.)
for
the
control
group.
All
the
patients
signed
their
informed
consent
which
included
them
in
this
study
protocol,
in
compliance
with
the
guidelines
of
the
institution’s
ethics
committee.
The
surgical
technique
was
standard
for
all
the
patients:
a
posterolateral
thoracotomy
was
performed
and
then
pleu-
ral
decortication,
as
described
by
Delorme
and
Deslauries.10
Two
rigid
32
F
ArgyleTM drains
were
placed,
one
anterior
and
the
other
posterior,
attached
to
a
Y
connector,
config-
ured
at
a
postoperative
suction
of
15
cm
H2O,
immediately
after
closure
of
the
thoracic
wall.
The
criteria
for
removal
of
the
drains
were:
air
leak
less
than
40
ml/min
in
the
past
12
h
for
the
DCD
patients,
and
lack
of
air
leak
for
the
tradi-
tional
drains
according
to
the
Modified
Robert
David
Cerfolio
(MRDC)
classification,
both
with
complete
lung
reexpansion
confirmed
by
chest
X-ray.
With
regard
to
the
amount
of
fluid
collected,
the
drain
was
removed
when
the
loss
was
less
than
2
ml/kg
in
24
h
(Table
1).
Air
leak
persisting
longer
than
7
days
was
considered
prolonged.4The
days
until
removal
of
the
drain,
the
days
of
hospital
stay,
and
the
number
and
type
of
complications
appearing
in
each
group
were
quantified.
524
J.M.
Mier
et
al.
Table
1
Variables
of
the
study
groups.
Variable
DCD
group
Traditional
group
p
results
Age
(years)
51±19.4
45.8±19.4
0.441
Gender
(M/F)
14/14
12/5
0.627
ATS
classification
of
the
empyema
(IIB/III)
4/14
8/9
0.122
Immediate
air
leak
1
(5%)
3
(17%)
0.261
Postoperative
Days
of
air
leak
2.5±1.8
2.4±2.2
0.966
Air
leak
(ml/min)
343
ml
N/A
N/A
Air
leak
MRDC
(0---5)
N/A
1.5
(5)
N/A
Air
leak
at
7th
day 2
(11%) 1
(5%) 0.581
Day
of
drain
removal 4.5±1.8 5.1±2.5 0.41
Days
of
hospitalisation 7.8±3.7 8.95±4.0 0.441
Complications
4
(22%)
7
(36%)
0.227
Reoperation
3
(16%)
5
(26%)
0.369
MRDC:
Modified
Robert
David
Cerfolio
Classification;
DCD:
digital
chest
drainage.
XLSTAT
for
Mac
was
used
for
the
statistical
analysis
and
the
Student’s
t-test
for
the
continuous
variables.
Statistical
significance
was
set
at
p
=
0.05.
Results
The
demographic
characteristics
are
similar.
Ninety-two
patients
were
recruited
during
the
time
period,
of
whom
57
were
excluded
due
to
an
exclusion
criterion.
None
of
the
patients
under
study
were
excluded,
and
none
of
the
patients
needed
to
be
discharged
home
with
a
drain
or
Heim-
lich
valve.
The
amount
of
air
leak
was
not
comparable
because
the
leak
measurement
scale
was
different
on
each
device:
in
ml/min
of
air
for
DCD,
and
on
a
scale
of
0 --- 5
for
the
Atrium-
OceanTM drains.
The
overall
leak
percentage
was
8%:
11%
in
the
DCD
group
and
5%
in
the
traditional
drainage
group
(p
=
0.581).
The
mean
air
leak
days
were
2.5±1.8
and
2.4±2.2,
respectively
(p
=
0.966).
The
drains
were
removed
on
days
4.5±1.8
and
5.1±2.5
(p
=
0.41),
the
days
of
hospital
stay
were
7.8±2.7
and
8.9±4.0
(p
=
0.441).
Finally,
the
complication
rate
was
22%
(4
patients)
vs
36%
(7
patients),
respectively
(p
=
0.227).
Three
patients
(16%)
of
the
DCD
group
had
to
be
reoperated
due
to
coagulated
haemothorax
vs
5
patients
(26%)
from
the
control
group
(p
=
0.369)
(Table
2).
Discussion
It
was
not
possible
in
this
study
to
identify
any
statisti-
cally
significant
result
on
comparing
the
Thopaz-MedelaTM
with
the
Atrium-OceanTM,
however
positive
tendencies
were
observed
in
terms
of
reduced
days
of
drainage,
days
of
hospital
stay
and
the
number
of
patients
who
required
reop-
eration
due
to
retained
haemothorax.
To
our
knowledge,
this
is
the
first
study
to
assess
the
results
of
DCD
in
patients
post
pleural
decortication.
Therefore
we
have
no
literature
with
which
to
contrast
our
results.
There
are
already
studies
that
show
reduced
days
of
chest
drainage
in
other
types
of
dis-
eases
using
DCD.5,6 However,
there
are
also
papers
that
refer
to
the
heterogeneity
of
the
groups
studied,
which
means
that
sometimes
it
is
questionable
whether
a
reduction
in
days
of
drainage
really
has
been
achieved.11
Our
study
only
included
empyema
at
stages
IIB
and
III.
These
are
patients
that
present
the
most
serious
technical
problems,
due
to
pleural
thickening.
Therefore,
postopera-
tive
blood
loss
and
air
leak
are
common
complications
that
can
even
require
reoperation.
In
our
study
we
observed
a
reduction
in
reoperation
in
the
DCD
group:
this
could
be
attributed
to
the
capacity
of
the
device
itself
to
main-
tain
continuous
suction
in
the
pleural
space,
which
stops
clots
forming
in
the
chest
and,
therefore,
the
drains
do
not
become
obstructed.
When
traditional
drains
are
placed,
Table
2
Surgical
complications.
Complication
DCD
group
Traditional
group
Haemothorax
3
2
Atelectasis
0
1
Prolonged
air
leak
2
1
Prolonged
fluid
leak
0
1
Residual
collection
0
2
Reoperation
3
(retained
haemothorax)
2
(retained
haemothorax)
1
(prolonged
air
leak)
2
(residual
collections)
The
Chi2test
was
used
and
no
significance
was
found
between
the
groups.
DCD:
digital
chest
drainage.
The
benefits
of
digital
chest
drainage
in
thoracic
empyema
525
suction
is
often
interrupted,
for
example
when
the
patient
is
being
moved,
on
ambulation,
etc.
It
is
also
important
to
stress
that
drains
can
occasionally
be
kinked
and
obstructed
by
the
patient’s
own
movements,
which
interrupts
suction.
This
event
is
alerted
immediately
by
the
alarm
mechanism
of
the
DCD,
which
means
the
problem
can
be
rapidly
solved
and
suction
is
not
interrupted.
In
terms
of
continuous
suction,
with
DCD
we
can
guarantee
and
monitor
that
the
suction
pro-
grammed
in
the
device
is
real.
Occasionally,
when
depending
on
wall
suction,
the
variability
can
be
unquantifiable.
We
found
no
significant
differences
in
the
time
of
removal
of
the
drain,
in
contrast
to
other
studies,
with
a
notable
reduction
in
days
of
drainage.
We
can
explain
this
because
with
empyema
air
leak
is
often
not
the
only
criterion
for
drain
removal;
the
amount
of
fluid
drained
and
its
charac-
teristics
are
also
very
important.
We
consider
that
a
weakness
of
our
study
is
the
small
sam-
ple
size.
However,
the
sample
size
calculations
indicate
that
16
patients
in
each
group
could
be
sufficient.
This
informa-
tion,
added
to
the
lack
of
studies
in
the
literature
with
the
same
diagnostic
and
treatment
characteristics
that
we
pro-
pose
in
our
study,
lead
us
to
believe
that
our
results
could
be
valid.
However,
more
numerous
series
or
multicentre
studies
might
draw
more
solid
conclusions.
To
conclude
our
study,
we
can
state
that
there
is
a
positive
tendency
for
DCD,
but
there
are
no
significant
dif-
ferences
in
terms
of
days
of
chest
drainage,
days
of
hospital
stay
or
complications
and
the
need
for
reoperation
between
the
DCD
and
the
traditional
systems.
Ethical
disclosures
Protection
of
human
and
animal
subjects.
The
authors
declare
that
no
experiments
were
performed
on
humans
or
animals
for
this
study.
Confidentiality
of
data.
The
authors
declare
that
they
have
followed
the
protocols
of
their
work
centre
on
the
publica-
tion
of
patient
data.
Right
to
privacy
and
informed
consent.
The
authors
have
obtained
the
written
informed
consent
of
the
patients
or
subjects
mentioned
in
the
article.
The
corresponding
author
is
in
possession
of
this
document.
Conflict
of
interest
The
authors
have
no
conflict
of
interests
to
declare.
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Full-text available
Article
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.
Full-text available
Article
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: might digital drains speed up the time to thoracic drain removal in terms of time till chest drain removal, hospital stay and overall cost? A total of 296 papers were identified as a result of the search as described below. Of these, five papers provided the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. A literature search revealed that several single-centre prospective randomized studies have shown significantly earlier removal of chest drains with digital drains ranging between 0.8 and 2.1 days sooner. However, there was heterogeneity in studies in the management protocol of chest drains in terms of the use of suction, number of drains and assessment for drain removal. Some protocols such as routinely keeping drains irrespective of the presence of air leak or drain output may have skewed results. Differences in exclusion criteria and protocols for discharging home with portable devices may have biased results. Due to heterogeneity in the management protocol of chest drains, there is conflicting evidence regarding hospital stay. The limited data on cost suggest that there may be significantly lower postoperative costs in the digital drain group. All the studies were single-centre series generally including patients with good preoperative lung function tests. Further larger studies with more robust chest drain management protocols are required especially to assess length of hospital stay, cost and whether the results are applicable to a larger patient population.
Full-text available
Article
Since digital thoracic drainage system (DTDS) came onto the market, a number of its advantages have become clear, for example that of eliminating the differences between observers. The withdrawal of thoracic drainage has been found to be comfortable, safe and well tolerated by patients; it helps to reduce or eliminate the cost of hospital stay, because, according to the different series published in recent months, it is possible to withdraw drainage sooner and thus discharge patients earlier. Prospective studies are underway, but as yet nothing has been written about the possible benefits in outpatient surgery programmes. In this report we present our findings of 3 cases of patients undergoing pulmonary resection who were treated with continuous intra-domiciliary DTDS. Pending the results of a prospective study now underway our observation is that with properly selected patients this is a safe method.
Full-text available
Article
Since there are no data in the literature regarding variability in the management of postoperative pleural drainages, we have designed a prospective randomized study aimed at measuring inter-observer variability in deciding when to withdraw chest tubes after lung resection and to evaluate if the use of an electronic device to measure postoperative air leak decreases clinical practice variations. Sixty-one patients undergoing pulmonary resection were randomly assigned to one of the following groups: digital group (electronic measure of pleural air leak using Millicore AB DigiVent chest drainage system) or traditional group (standard water seal pleural chamber). Chest tube withdrawal criteria were established in advance. During morning rounds, two thoracic surgeons with comparable clinical experience and blinded to the decision of their counterpart, evaluated chest tube withdrawal criteria and noted whether the tube should be withdrawn or not. Inter-observer variability kappa index and global, positive, and negative agreement rates were calculated on 2 x 2 tables. Each observation episode was considered in the calculation. Fifty-four observations were recorded in the traditional group. Kappa coefficient was 0.37 (overall agreement rate: 0.58; positive agreement rate: 0.72; and negative agreement rate: 0.64). In the digital group, 67 observations were recorded. Kappa coefficient was 0.88 (overall agreement rate: 0.94; positive agreement rate 0.94; and negative agreement rate 0.94). We have demonstrated a high rate of disagreement related to the indication to remove chest tubes after lung resection and the improvement of the agreement rate with the use of an electronic device to measure postoperative air leak and pleural pressures.
Article
Sixty years after the birth of Thoracic Surgery at the National Institute of Respiratory Diseases, its evolution can be associated to significant events in the field of Medicine in Mexico and the world. When the tuberculosis bacillus was discovered, one of the best alternatives for treatment was surgery. At the beginning of the century, the news in Mexico talked about the consequences of tuberculosis. At the same time, the Mexican revolution had started. Thoracic surgery emerged together with these events. At that time, Tlalpan was a war field for Zapatistas and constitutionalists. In 1930, General Lázaro Cárdenas decreed the construction of a tuberculosis sanatorium, which was concluded in 1935. The Thoracic Surgery service was inaugurated on January 11, 1944. Along the twentieth century the medicine that involved thoracic surgery progressed notoriously. The first bronchoscopy was performed in 1933, and the first lobectomy in 1943. The first intracardiac angiocardiography was made in 1946 as well as the first arterial closure. Meanwhile, the structure of the country changed significantly. The first heart transplant was done in 1967, and survived 18 days. Various types of surgery were developed, some of which have presently been abandoned, like extra pleural pneumothorax, pulmonary collapse surgery and fistulectomies, and other procedures have been improved, like open lung biopsy and pleural decortication. A total of 17,083 surgical procedures were recorded in the first 50 years of the service. During the last 20 years we have practiced the most innovative techniques of surgery such as video surgery, mediastinostomy, extended mediastinoscopy, use of LASER in the airway and auto suture techniques, as long as unilateral lung transplant, tromboendarterectomy, tracheal surgery and lung volume reduction surgery. The new and universal profile of thoracic surgeons has been integrated to the service as human resources formation with institutional representation in several States of Mexico, Central America, South America and the Caribbean.
Article
Background: The aim of this study was to assess the impact of digital versus traditional drainage devices on chest tube removal and patient satisfaction. Methods: A randomized trial of digital versus traditional devices after lobectomy/segmentectomy was conducted at 4 international centers (United Kingdom, Europe, Asia, United States). Patients were managed with overnight suction followed by gravity drainage. Chest tubes were removed when an air leak was not evident anymore and the drained fluid was less than 400 mL/d. Results: The groups (digital, 191 patients; traditional, 190 patients) were well matched for baseline and surgical characteristics. There were 325 lobectomies/bilobectomies and 56 segmentectomies, 308 of which were performed by video-assisted thoracic surgery (VATS). Patients randomized to digital systems had a significantly shorter air leak duration (1.0 versus 2.2 days; p=0.001), duration of chest tube placement (3.6 versus 4.7 days; p=0.0001), and postoperative length of stay (4.6 versus 5.6 days; p<0.0001). Subjective end points revealed a perceived improved ability to arise from bed (p=0.008), system convenience for patients and personnel (p=0.02), and the potential for being comfortable when discharged home with the device (p=0.06). A mean difference of 2.6 days from air leak cessation to tube removal was observed, which was similar in the 2 groups (p=0.7). Multivariable regression analysis showed that duration of chest tube placement after air leak cessation was directly associated with the amount of fluid drained during the first 48 hours (p=0.01) and the duration of air leak (p=0.008), independent of hospital location. Conclusions: Patients managed with digital drainage systems experienced a shorter duration of chest tube placement, shorter hospital stays, and higher satisfaction scores compared with those managed with traditional devices. ( Clinical trial registration number: NCT01747889.).
Article
Although video-assisted thoracic surgery (VATS) pleural drainage and decortication have been proven to be effective treatments in the early stages of empyema, the optimal timing of VATS is still not clear. To assess the effectiveness of early VATS drainage and decortication, we reviewed the records of patients who underwent VATS and open decortication for empyema. One hundred twenty-eight patients with empyema were treated with VATS and open decortication over 8 years at Korea University Anam Hospital. The VATS patients (120 patients) were divided into 3 groups based on the interval between the onset of chest symptoms and the time of operation (group 1: <2 weeks; group 2: 2 to 4 weeks; group 3: >4 weeks). Additional 8 open decortication patients with symptom durations greater than 4 weeks were compared with group 3 patients. Groups 1 and 2 showed shorter chest tube duration, postoperative hospital stay, surgical procedure time, and fewer prolonged air leaks than group 3. No significant difference was noted between groups 1 and 2; and no difference was noted in the length of postoperative intensive care unit stays or the reintervention and reoperation rates among the 3 groups. In chronic empyema patients, group 3 showed shorter chest tube duration than the open decortication group. Patients with symptom durations of less than 4 weeks showed better early results than those with symptom durations greater than 4 weeks. Thus, symptom duration can be considered a reliable preoperative factor in deciding the surgical management of empyema or cases involving loculated pleural effusion.
Article
La fuga aérea persistente es una de las más frecuentes complicaciones después de una resección pulmonar. Debido a las diferencias de parámetros subjetivos para la retirada del drenaje en el postoperatorio, nosotros diseñamos un estudio prospectivo, comparativo y consecutivo para evaluar de una manera objetiva cómo los dispositivos digitales (Thopaz® y Digivent®) pueden medir la fuga aérea comparándolos entre ellos y, a su vez, con Pleur-Evac®, en beneficio de una retirada precoz del drenaje torácico.
Article
Decortication is a surgical procedure that consists in restoring the ventilatory function of the lung by removing the constricting membrane that compresses it over the mediastinum. The constricting membrane is the last stage of loculated and complicated pleural effusions: haemothorax, empyemas, pleural tuberculosis, various other pleural diseases and sequellae of earlier collapsotherapeutic procedures. Decortication typically involves removal of the entire complicated pleural disease, freeing the visceral pleura (decortication strico sensu) and the parietal pleura (pleurectomy). After decortication the lung can expand again and improved functioning can be expected. Multiple technical procedures are available. When the pleural thickening is induced by underlying lung disease, it may be necessary to resect the underlying diseased parenchyma during the same intervention. In chronic parapneumonic empyemas, the current availability of video-assisted procedures allows to avoid thoracotomy for decortication.
Article
The objective of this randomised trial was to assess the effectiveness of a new fast-track chest tube removal protocol taking advantage of digital monitoring of air leak compared to a traditional protocol using visual and subjective assessment of air leak (bubbles). One hundred and sixty-six patients submitted to pulmonary lobectomy for lung cancer were randomised in two groups with different chest tube removal protocols: (1) in the new protocol, chest tube was removed based on digitally recorded measurements of air leak flow; (2) in the traditional protocol, the chest tube removal was based on an instantaneous assessment of air leak during daily rounds. The two groups were compared in terms of chest tube duration, hospital stay and costs. The two groups were well matched for several preoperative and operative variables. Compared to the traditional protocol, the new digital recording protocol showed mean reductions in chest tube duration (p=0.0007), hospital stay (p=0.007) of 0.9 day, and a mean cost saving of euro 476 per patient (p=0.008). In the new chest tube removal protocol, 51% of patients had their chest tube removed by the second postoperative day versus only 12% of those in the traditional protocol. The application of a chest tube removal protocol using a digital drainage unit featuring a continuous recording of air leak was safe and cost effective. Although future studies are warranted to confirm these results in other settings, the use of this new protocol is now routinely applied in our practice.
Article
This study aimed to assess prospectively the accuracy, safety and outcome of flex-rigid pleuroscopy in the diagnosis of patients with indeterminate pleural effusions. Included in the study were all patients with unilateral exudative pleural effusions of unknown aetiology who underwent diagnostic flex-rigid pleuroscopy from July 2003 to June 2005, and were followed until December 2005. The procedure was conducted in the endoscopy suite under local anaesthesia and, where indicated, talc poudrage was carried out at the same time. Clinical data, length of hospitalization, chest tube drainage, outcome, diagnostic accuracy of pleuroscopy and procedure-related adverse events were recorded prospectively. Fifty-one patients were recruited (20 male and 31 female). Median age was 53 years (range 45-67). Flex-rigid pleuroscopy was 96% accurate and yielded a diagnosis in 49 out of 51 patients. It was safely carried out without need for surgical intervention, blood transfusion or endotracheal intubation. Culture-negative fever was observed in eight patients (16%), and five patients (10%) required additional analgesia for postoperative pain. Duration of chest tube drainage and length of stay for patients who underwent diagnostic pleuroscopy were 1 and 2 days, respectively, while they were both 3 days when talc poudrage was carried out. Success rates with pleuroscopic talc pleurodesis for malignant pleural effusions were 94%, 92% and 89.5% at 3, 6 and 12 months, respectively, and the 30-day mortality was 0%. Flex-rigid pleuroscopy is a safe procedure with a high diagnostic accuracy and should be considered for the evaluation of indeterminate pleural effusion.