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Leivaditis V, Skevis K, Mulita F, Tsalikidis C, Mitsala A, Dahm M, Grapatsas K, Papatriantafyllou A, Markakis K, Kefaloyannis E, Christou G, Pitiakoudis M, Koletsis E. Advancements in the Management of Postoperative Air Leak following Thoracic Surgery: From Traditional Practices to Innovative Therapies. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:802. [PMID: 38792985 PMCID: PMC11123218 DOI: 10.3390/medicina60050802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024]
Abstract
Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient's needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.
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Affiliation(s)
- Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, 67655 Kaiserslautern, Germany; (V.L.); (M.D.); (A.P.)
| | - Konstantinos Skevis
- Department of Thoracic Surgery, General Hospital of Rhodos, 85133 Rhodos, Greece;
| | - Francesk Mulita
- Department of General Surgery, Patras University Hospital, 26504 Patras, Greece;
| | - Christos Tsalikidis
- Second Department of Surgery, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.)
| | - Athanasia Mitsala
- Second Department of Surgery, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.)
| | - Manfred Dahm
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, 67655 Kaiserslautern, Germany; (V.L.); (M.D.); (A.P.)
| | - Konstantinos Grapatsas
- Department of Thoracic Surgery and Thoracic Endoscopy, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, 45239 Essen, Germany;
| | - Athanasios Papatriantafyllou
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, 67655 Kaiserslautern, Germany; (V.L.); (M.D.); (A.P.)
| | - Konstantinos Markakis
- Department of Cardiothoracic Surgery, General Hospital of Nicosia, 2031 Nicosia, Cyprus;
| | - Emmanuel Kefaloyannis
- Department of Thoracic Surgery, University Hospital of Heraklion, 71500 Heraklion, Greece;
| | - Glykeria Christou
- Department of Thoracic Surgery, KAT Attica General Hospital, 14561 Athens, Greece;
| | - Michail Pitiakoudis
- Second Department of Surgery, Democritus University of Thrace Medical School, 68100 Alexandroupolis, Greece; (C.T.); (A.M.)
| | - Efstratios Koletsis
- Department of Cardiothoracic Surgery, Patras University Hospital, 26504 Patras, Greece;
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2
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Barton EC, Maskell NA, Walker SP. Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions. Semin Respir Crit Care Med 2023. [PMID: 37321247 DOI: 10.1055/s-0043-1769615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
For decades, there has been scanty evidence, most of which is of poor quality, to guide clinicians in the assessment and management of pneumothorax. A recent surge in pneumothorax research has begun to address controversies surrounding the topic and change the face of pneumothorax management. In this article, we review controversies concerning the etiology, pathogenesis, and classification of pneumothorax, and discuss recent advances in its management, including conservative and ambulatory management. We review the evidence base for the challenges of managing pneumothorax, including persistent air leak, and suggest new directions for future research that can help provide patient-centered, evidence-based management for this challenging cohort of patients.
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Affiliation(s)
- Eleanor C Barton
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Nick A Maskell
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Steven P Walker
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
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3
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Adachi H, Wakimoto S, Ando K, Yamamoto T, Saito Y, Shiono S, Woo T, Ito H, Sakao Y, Sawabata N. Optimal Chest Drainage Method After Anatomic Lung Resection: A Prospective Observational Study. Ann Thorac Surg 2023; 115:845-852. [PMID: 35868556 DOI: 10.1016/j.athoracsur.2022.06.042] [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: 12/23/2021] [Revised: 06/20/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several methods for chest drainage after pulmonary resection of malignant lung tumors exist, but consensus on the ideal method has not been reached. METHODS We conducted a multicenter prospective observational study. We enrolled 2200 patients who underwent lung resection for lung tumors. Of the 1470 patients who underwent anatomic resection, 347 showed air leak on the morning of postoperative day 1. They were assigned to 3 groups according to the chest drainage method on postoperative day 1. RESULTS Of 347 patients with postoperative air leaks, 107 (30.8%), 179 (51.6%), and 61 (17.6%) were assigned to water seal, continuous suction, and digital drainage, respectively. The median postoperative air leak duration was significantly longer with digital drainage (4.0 days) than with either water seal (2.5 days) or continuous suction (3.0 days; P = .009). Chest tubes were required for significantly more days on average with digital drainage (6.0 days) than with water seal (4.0 days) or continuous suction (4.0 days; P = .003). Prolongation of air leak duration was significantly more likely to occur in patients with body mass index <18.5 kg/m2 (hazard ratio [HR], 1.6; 95% CI, 1.1-2.3), moderate or severe air leak on postoperative day 1 (HR, 2.0; 95% CI, 1.5-2.6), or digital drainage (HR, 1.4; 95% CI, 1.01-1.9). CONCLUSIONS Water seal was associated with significantly shorter duration of postoperative air leak and chest drainage compared with continuous suction and digital drainage.
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Affiliation(s)
- Hiroyuki Adachi
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan; Department of General Thoracic Surgery, Kanto-Rosai Hospital, Kawasaki, Japan.
| | - Shin Wakimoto
- Department of Thoracic Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya, Japan
| | - Kohei Ando
- Department of General Thoracic Surgery, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Taketsugu Yamamoto
- Department of Thoracic Surgery, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yuichi Saito
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Satoshi Shiono
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Tekkan Woo
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Ito
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Yukinori Sakao
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Noriyoshi Sawabata
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara, Japan
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4
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Chang PC, Chen KH, Jhou HJ, Lee CH, Chou SH, Chen PH, Chang TW. Promising Effects of Digital Chest Tube Drainage System for Pulmonary Resection: A Systematic Review and Network Meta-Analysis. J Pers Med 2022; 12:jpm12040512. [PMID: 35455628 PMCID: PMC9029690 DOI: 10.3390/jpm12040512] [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: 02/26/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Po-Chih Chang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan; (P.-C.C.); (S.-H.C.)
- Weight Management Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan
- Ph.D. Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan
- Department of Sports Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan
| | - Kai-Hua Chen
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan;
| | - Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua 50006, Taiwan;
| | - Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei City 11490, Taiwan;
| | - Shah-Hwa Chou
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan; (P.-C.C.); (S.-H.C.)
- Department of Surgery, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan
- Correspondence: (P.-H.C.); (T.-W.C.); Tel.: +886-7-3121101 (ext. 6206)
| | - Ting-Wei Chang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan;
- Correspondence: (P.-H.C.); (T.-W.C.); Tel.: +886-7-3121101 (ext. 6206)
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Abstract
Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.
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Abstract
OBJECTIVE To describe the physiology of air leak in bronchopleural fistula in mechanically ventilated patients and how understanding of its physiology drives management of positive-pressure ventilation. To provide guidance of lung isolation, mechanical ventilator, pleural catheter, and endobronchial strategies for the management of bronchopleural fistula on mechanical ventilation. DATA SOURCES Online search of PubMed and manual review of articles (laboratory and patient studies) was performed. STUDY SELECTION Articles relevant to bronchopleural fistula, mechanical ventilation in patients with bronchopleural fistula, independent lung ventilation, high-flow ventilatory modes, physiology of persistent air leak, extracorporeal membrane oxygenation, fluid dynamics of bronchopleural fistula airflow, and intrapleural catheter management were selected. Randomized trials, observational studies, case reports, and physiologic studies were included. DATA EXTRACTION Data from selected studies were qualitatively evaluated for this review. We included data illustrating the physiology of driving pressure across a bronchopleural fistula as well as data, largely from case reports, demonstrating management and outcomes with various ventilator modes, intrapleural catheter techniques, endoscopic placement of occlusion and valve devices, and extracorporeal membrane oxygenation. Themes related to managing persistent air leak with mechanical ventilation were reviewed and extracted. DATA SYNTHESIS In case reports that demonstrate different approaches to managing patients with bronchopleural fistula requiring mechanical ventilation, common themes emerge. Strategies aimed at decreasing peak inspiratory pressure, using lower tidal volumes, lowering positive end-expiratory pressure, decreasing the inspiratory time, and decreasing the respiratory rate, while minimizing negative intrapleural pressure decreases airflow across the bronchopleural fistula. CONCLUSIONS Mechanical ventilation and intrapleural catheter management must be individualized and aimed at reducing air leak. Clinicians should emphasize reducing peak inspiratory pressures, reducing positive end-expiratory pressure, and limiting negative intrapleural pressure. In refractory cases, clinicians can consider lung isolation, independent lung ventilation, or extracorporeal membrane oxygenation in appropriate patients as well as definitive management with advanced bronchoscopic placement of valves or occlusion devices.
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Geraci TC, Chang SH, Shah SK, Kent A, Cerfolio RJ. Postoperative Air Leaks After Lung Surgery: Predictors, Intraoperative Techniques, and Postoperative Management. Thorac Surg Clin 2021; 31:161-169. [PMID: 33926669 DOI: 10.1016/j.thorsurg.2021.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.
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Affiliation(s)
- Travis C Geraci
- Department of Cardiothoracic Surgery, New York University Langone Health, 550 1st Avenue, 15th Floor, New York, NY 10016, USA.
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, New York University Langone Health, 550 1st Avenue, 15th Floor, New York, NY 10016, USA
| | - Savan K Shah
- Department of Cardiothoracic Surgery, New York University Langone Health, 550 1st Avenue, 15th Floor, New York, NY 10016, USA
| | - Amie Kent
- Department of Cardiothoracic Surgery, New York University Langone Health, 550 1st Avenue, 15th Floor, New York, NY 10016, USA
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, 550 1st Avenue, 15th Floor, New York, NY 10016, USA
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8
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Kreso A, Mathisen DJ. Management of Air Leaks and Residual Spaces Following Lung Resection. Thorac Surg Clin 2021; 31:265-271. [PMID: 34304834 DOI: 10.1016/j.thorsurg.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Air leaks and residual airspaces following lung resection are common problems in thoracic surgery. Prolonged air leaks frequently necessitate extended hospitalization. This is true whether the surgery was done in an open fashion or with video-/robot-assisted thoracic surgery. In this review, the authors present common risk factors that predispose to prolonged air leaks and discuss the management options for air leaks by focusing on intraoperative maneuvers, postoperative considerations, and options for difficult-to-manage air leaks and spaces. They also discuss options to prevent such spaces and present management approaches to take care of patients with these challenging problems.
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Affiliation(s)
- Antonia Kreso
- Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street Founders 7, Boston, MA 02114, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street Founders 7, Boston, MA 02114, USA.
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9
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Mitsui S, Tauchi S, Uchida T, Ohnishi H, Shimokawa T, Tobe S. Low suction on digital drainage devices promptly improves post-operative air leaks following lung resection operations: a retrospective study. J Cardiothorac Surg 2021; 16:105. [PMID: 33882977 PMCID: PMC8059315 DOI: 10.1186/s13019-021-01485-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We investigated the most effective suction pressure for preventing or promptly improving postoperative air leaks on digital drainage devices after lung resection. METHODS We retrospectively analyzed the postoperative data of 242 patients who were monitored with a digital drainage system after pulmonary resection in our institution between December 2017 and June 2020. We divided the patients into three groups according to the suction pressure used: A (low-pressure suction group: - 5 cm H2O), B (intermediate-pressure group: - 10 cm H2O), and C (high-pressure suction group: - 20 cm H2O). We evaluated the duration of air leaks, timing of chest tube replacement, the amount of postoperative air leak, volume of fluid drained before chest tube removal, and the total number of air leaks during drainage. RESULTS In total, 217 patients were included in this study. The duration of air leaks gradually decreased with significant difference between the groups, the highest decrease in A, the lowest decrease in C (P = 0.019). Timing of chest tube replacement, on the other hand, did not significantly differ between the three groups (P = 0.126). The number of postoperative air leaks just after surgery did not significantly differ between the three groups (P = 0.175), but the number of air leaks on postoperative day 1 were fewest in group A, then B, and greatest in group C (P = 0.033). The maximum amount of air leaks during drainage was lowest in A, then B, and highest in C (P = 0.036). Volume of fluid drained before chest tube removal did not significantly differ between the three groups (P = 0.986). CONCLUSION Low-pressure suction after pulmonary resection seems to avoid or promptly improve postoperative air leaks in digital drainage devices after lung resection. TRIAL REGISTRATION This is a single-institution, retrospective analysis-based study of data from an electronic database. Study protocol was approved by the Akashi Medical Center Institutional Research Ethics Board (approval number: 2020-9).
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Affiliation(s)
- Suguru Mitsui
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan
| | - Shunsuke Tauchi
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan.
| | - Takahiro Uchida
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan
| | - Hisashi Ohnishi
- Department of Respiratory Medicine, Akashi Medical Center, Akashi, Japan
| | - Toshio Shimokawa
- Clinical Study Center, School of Medicine, Wakayama Medical University Hospital, Wakayama, Japan
| | - Satoshi Tobe
- Department of Thoracic Surgery, Akashi Medical Center, 743-33 Okubocho Yagi, Akashi, Hyogo, 674-0063, Japan
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Abstract
It is very difficult to find certain surgical field in which surgeon's decision is absolutely evidence-based. The objective of evidence-based medicine (and surgery) is offering the best treatment for each patient that should encourage conducting the randomized trials (RT) as the highest level of evidence. The results of RTs often contradict the existing clinical experience, and experience per se does not always confirm the significance of the results obtained. One cannot make any conclusions based on RT data. Treatment strategy for a particular patient remains unclear. The authors have analyzed the results of large-scale RTs devoted to laparoscopic cholecystectomy, rectal surgery, lung cancer surgery, postoperative care, treatment of pulmonary emphysema. It was shown that RT data as the highest level of evidence are not always true for surgery. In most clinical situations, the decision is not based on RT results. The desire of surgeons to master a new technique is often more significant than patient care, while clinical experience and the laws of the market are more important than science. There is no doubt that knowledge of RT results are essential in training period, but this means quite a bit for a particular patient. The best decision can be made during discussion and conversation with colleagues, where an experience of each specialist will have the same value as the best evidence.
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Affiliation(s)
- A L Akopov
- Pavlov First St. Petersburg Medical University, St. Petersburg, Russia
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11
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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12
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DeArmond DT, Das NA, Restrepo CS, Katona MA, Johnson SB, Hernandez BS, Michalek JE. Intrapleural Impedance Sensor Real-Time Tracking of Pneumothorax in a Porcine Model of Air Leak. Semin Thorac Cardiovasc Surg 2019; 32:357-366. [PMID: 31610232 DOI: 10.1053/j.semtcvs.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 11/11/2022]
Abstract
In patients with alveolar-to-pleural air leak due to recent surgery or trauma, clinicians tend to manage chest tubes with suction therapy. Nonsuction therapy is associated with shorter chest tube duration but also a higher risk of pneumothorax. We sought to develop an intrapleural electrical impedance sensor for continuous, real-time monitoring of pneumothorax development in a porcine model of air leak as a means of promoting nonsuction therapy. Using thoracoscopy, 2 chest tubes and the pleural impedance sensor were introduced into the pleural space of 3 pigs. Continuous air leak was introduced through 1 chest tube by carbon dioxide insufflation. The second chest tube was placed to suction then transitioned to no suction at increasingly higher air leaks until pneumothorax developed. Simultaneously, real-time impedance measurements were obtained from the pleural sensor. Fluoroscopy spot images were captured to verify the presence or absence of pneumothorax. Statistical Analysis Software was used throughout. With the chest tube on suction, a fully expanded lung was identified by a distinct pleural electrical impedance respiratory waveform. With transition of the chest tube to water seal, loss of contact of the sensor with the lung resulted in an immediate measurement of infinite electrical impedance. Pneumothorax resolution by restoring suction therapy was detected in real time by a return of the normal respiratory impedance waveform. Pleural electrical impedance monitoring detected pneumothorax development and resolution in real time. This simple technology has the potential to improve the safety and quality of chest tube management.
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Affiliation(s)
- Daniel T DeArmond
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas.
| | - Nitin A Das
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas
| | | | - Mitch A Katona
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas
| | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, Texas
| | - Brian S Hernandez
- Department of Epidemiology & Biostatistics, UTHSCSA, San Antonio, Texas
| | - Joel E Michalek
- Department of Epidemiology & Biostatistics, UTHSCSA, San Antonio, Texas
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13
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Abu-Hijleh M, Styrvoky K, Anand V, Woll F, Yarmus L, Machuzak MS, Nader DA, Mullett TW, Hogarth DK, Toth JW, Acash G, Casal RF, Hazelrigg S, Wood DE. Intrabronchial Valves for Air Leaks After Lobectomy, Segmentectomy, and Lung Volume Reduction Surgery. Lung 2019; 197:627-633. [PMID: 31463549 DOI: 10.1007/s00408-019-00268-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/21/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Air leaks are common after lobectomy, segmentectomy, and lung volume reduction surgery (LVRS). This can increase post-operative morbidity, cost, and hospital length of stay. The management of post-pulmonary resection air leaks remains challenging. Minimally invasive effective interventions are necessary. The Spiration Valve System (SVS, Olympus/Spiration Inc., Redmond, WA, US) is approved by the FDA under humanitarian use exemption for management of prolonged air leaks. METHODS This is a prospective multicenter registry of 39 patients with air leaks after lobectomy, segmentectomy, and LVRS managed with an intention to use bronchoscopic SVS to resolve air leaks. RESULTS Bronchoscopic SVS placement was feasible in 82.1% of patients (32/39 patients) and 90 valves were placed with a median of 2 valves per patient (mean of 2.7 ± 1.5 valves, range of 1 to 7 valves). Positive response to SVS placement was documented in 76.9% of all patients (30/39 patients) and in 93.8% of patients when SVS placement was feasible (30/32 patients). Air leaks ultimately resolved when SVS placement was feasible in 87.5% of patients (28/32 patients), after a median of 2.5 days (mean ± SD of 8.9 ± 12.4 days). Considering all patients with an intention to treat analysis, bronchoscopic SVS procedure likely contributed to resolution of air leaks in 71.8% of patients (28/39 patients). The post-procedure median hospital stay was 4 days (mean 6.0 ± 6.1 days). CONCLUSIONS This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.
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Affiliation(s)
- Muhanned Abu-Hijleh
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, POB Building II, Dallas, TX, 75390, USA.
| | - Kim Styrvoky
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vikram Anand
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fernando Woll
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Section of Interventional Pulmonology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael S Machuzak
- Department of Pulmonary, Allergy, Critical Care Medicine and Transplant Center, Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Nader
- Department of Medicine, Pulmonary and Critical Care Medicine, Interventional Pulmonology, Cancer Treatment Centers of America, Tulsa, OK, USA
| | - Timothy W Mullett
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - D Kyle Hogarth
- Section of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Jennifer W Toth
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ghazwan Acash
- Department of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Lahey Hospital and Medical Center, Tufts University School of Medicine, Burlington, MA, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, Interventional Pulmonology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Stephen Hazelrigg
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Douglas E Wood
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
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14
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Zhou J, Chen N, Hai Y, Lyu M, Wang Z, Gao Y, Pang L, Liao H, Liu L. External suction versus simple water-seal on chest drainage following pulmonary surgery: an updated meta-analysis. Interact Cardiovasc Thorac Surg 2019; 28:29-36. [PMID: 30052997 DOI: 10.1093/icvts/ivy216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/12/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES The decision to apply simple water-seal drainage or the addition of an external suction to the simple water-seal drainage following pulmonary surgery is made based on the surgeon's experience or preference and has remained controversial. This meta-analysis aimed to assess the effects of the addition of suction to simple water-seal on the postoperative outcomes. METHODS PubMed, EMBASE and Web of Science were searched from their inception to 30 August 2017. The risk ratio and the weight mean difference were calculated for dichotomous and continuous outcomes, respectively, each with 95% confidence intervals (CIs). The heterogeneity and risk of bias were also assessed. RESULTS A total of 10 randomized controlled trials enrolling 1601 patients were included. Overall, compared with simple water-seal, the addition of external suction reduced the occurrence of postoperative pneumothorax (risk ratio 0.35, 95% CI 0.13-0.93; P = 0.04) and other cardiopulmonary complications (risk ratio 0.65, 95% CI 0.48-0.89; P = 0.008), and increased the duration of chest tube drainage (weight mean difference 0.92 days, 95% CI 0.04-1.81, P = 0.04). However, the effect difference between the 2 groups was not significant regarding air leak duration, length of hospital stay and the occurrence of prolonged air leak. The stability of these studies was strong. No evidence of publication bias was detected. CONCLUSIONS The addition of suction to simple water-seal made no difference to air leak duration, hospital stay or the occurrence of prolonged air leak following pulmonary surgery. In patients where there is concern about a residual or increasing pneumothorax, the addition of suction may be applied selectively.
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Affiliation(s)
- Jian Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Nan Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Yang Hai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Mengyuan Lyu
- West China School of Medicine, Sichuan University, Chengdu, China.,Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zihuai Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Yuanjing Gao
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Long Pang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Hu Liao
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,Western China Collaborative Innovation Center for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,Western China Collaborative Innovation Center for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, China
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15
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Filosso PL, Guerrera F, Lausi PO, Ruffini E. How should we manage the chest drainage after a video-assisted thoracoscopic surgery lobectomy? J Thorac Dis 2019; 11:2212-2214. [PMID: 31372255 DOI: 10.21037/jtd.2019.05.44] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Pier Luigi Filosso
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Turin, Turin, TO, Italy
| | - Francesco Guerrera
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Turin, Turin, TO, Italy
| | - Paolo Olivo Lausi
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Turin, Turin, TO, Italy
| | - Enrico Ruffini
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Turin, Turin, TO, Italy
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16
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French DG, Gilbert S. Technology and evidence-based care enhance postoperative management of chest drains. J Thorac Dis 2018; 10:6399-6403. [PMID: 30746174 DOI: 10.21037/jtd.2018.11.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, Dalhousie University, Queen Elizabeth II Hospital-Victoria Campus, Halifax, NS, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
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17
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French DG, Plourde M, Henteleff H, Mujoomdar A, Bethune D. Optimal management of postoperative parenchymal air leaks. J Thorac Dis 2018; 10:S3789-S3798. [PMID: 30505566 DOI: 10.21037/jtd.2018.10.05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Air leaks are the most common complication after pulmonary resection. Enhanced recovery after surgery (ERAS) programs must be designed to manage parenchymal air leaks. ERAS programs should consider two components when creating protocols for air leaks: assessment and management. Accurate assessment of air leaks using traditional analogues devices, newer digital drainage systems, portable devices and chest X-rays (CXR) are reviewed. Published data suggests that digital drainage systems result in a more confident assessment of air leaks. The literature regarding the management of postoperative air leaks, including the number of chest tubes, the role of applied external suction, invasive maneuvers and discharge with a portable device is reviewed. The key findings are that a single chest drain is adequate in the majority of cases to manage an air leak, the use of applied external suction is unlikely to prevent or prolong an air leak, autologous blood patch pleurodesis may potentially shorten postoperative air leaks and there is sufficient data to support that patients can safely be discharged with a portable drainage system. There is also literature to support the design of protocols for management of postoperative air leaks. Standardization of postoperative care through ERAS programs will allow for the design of larger RCTs to better understand some of the controversies around the management of postoperative air leaks.
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Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Madelaine Plourde
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Harry Henteleff
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Aneil Mujoomdar
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Drew Bethune
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
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18
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Carlucci P, Trigiani M, Mori PA, Mondoni M, Pinelli V, Casalini AG, Conte EG, Buggio G, Villari L, Marchetti G. Competence in pleural procedures. Panminerva Med 2018; 61:326-343. [PMID: 30394712 DOI: 10.23736/s0031-0808.18.03564-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Diseases of the pleura and pleural space are common and present a significant contribution to the workload of respiratory physicians, with most cases resulting from congestive heart failure, pneumonia, and cancer. Although the radiographic and ultrasonographic detection of pleural abnormalities may be obvious, the determination of a specific diagnosis can often represent a challenge. Invasive procedures such as pleural drainage, ultrasound/CT-guided pleural biopsy or medical thoracoscopy can be useful in determining specific diagnosis of pleural diseases. Management of primary and secondary spontaneous pneumothorax is mandatory in an interventional pulmonology training program, while the medical or surgical treatment of the recurrence is still a matter of discussion. Pleural drainage is a diagnostic and therapeutic procedure used in the treatment of pneumothorax and pleural effusions of different etiologies and even in palliation of symptomatic in malignant pleural effusion. Medical thoracoscopy (MT) is a minimally invasive procedure aimed at inspecting the pleural space. It could be a diagnostic procedure in pleural effusions (suspected malignant pleural effusion, infective pleural disease such as empyema or tuberculosis) or therapeutic procedure (chemical pleurodesis or opening of loculation in empyema). Diagnostic yield is 95% in patients with pleural malignancies and higher in pleural tuberculosis. In parapneumonic complex effusion, MT obviates the need for surgery in most cases. Thoracoscopy training should be considered being as important as bronchoscopy training for interventional pulmonology, although prior acquisition of ultrasonography and chest tube insertion skills is essential.
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Affiliation(s)
- Paolo Carlucci
- Respiratory Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy -
| | - Marco Trigiani
- SOD Pneumologia Interventistica AOUC, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Pier A Mori
- Unit of Pulmonology and Thoracic Endoscopy, University Hospital of Parma, Parma, Italy
| | - Michele Mondoni
- Respiratory Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - Valentina Pinelli
- Division of Pneumology, Ospedale San Bartolomeo, Sarzana, La Spezia, Italy
| | - Angelo G Casalini
- Unit of Pulmonology and Thoracic Endoscopy, University Hospital of Parma, Parma, Italy
| | - Emanuele G Conte
- Division of Pneumology, "C. e G. Mazzoni" Hospital, Ascoli Piceno, Italy
| | - Giuseppe Buggio
- Department of Pneumology, San Bassiano Hospital, Bassano del Grappa, Vicenza, Italy
| | - Liliana Villari
- Division of Pneumology, AUSL Toscana Nord-Ovest, Apuane Hospital, Massa, Italy
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19
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Patella M, Saporito A, Mongelli F, Pini R, Inderbitzi R, Cafarotti S. Management of residual pleural space after lung resection: fully controllable paralysis of the diaphragm through continuous phrenic nerve block. J Thorac Dis 2018; 10:4883-4890. [PMID: 30233862 DOI: 10.21037/jtd.2018.07.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Residual pleural space after lung resection associated with air leak is a challenging issue, potentially causing serious complications. We report a new, postoperative technique to reduce the pleural space, inducing a controlled and reversible paralysis of the diaphragm. Methods Ten patients were enrolled (7 lobectomies, 2 bilobectomy, 1 wedge resection). Inclusion criteria were: digitally detected air flow >200 mL/min at post-op day 3, presence of empty pleural space at chest x-ray, absence of restrictive lung disease, absence of known arrhythmias. A 22G nerve-block catheter was place under ultrasound guidance in proximity to the phrenic nerve, between the sternocleidomastoid muscle and the anterior scalene muscle at the level of 6th cervical vertebra. Continuous infusion of ropivacaine 0.2% 3 mL/h was started. Fluoroscopy was used to confirm significant reduction in hemidiaphragm movements. Monitoring of vital signs and intense respiratory physiotherapy were enhanced. The infusion was stopped at air leak cessation and the catheter was removed along with the chest drain. Results No peri- and post-procedural complications occurred. In all patients, we observed an immediate reduction of the empty pleural space and resolution of the air leak within few days (3±1.16 days). After suspension of local anaesthetic, complete restoration of the hemidiaphragm function has been documented. Conclusions This is an effective and minimally invasive method to reduce the residual pleural space after lung resections. Narrowing of the pleural space facilitates the contact between the lung and the chest wall promoting the resolution of the air leak. Diaphragm paralysis is controlled and temporary with no residual disabilities.
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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
| | - Francesco Mongelli
- Department of Thoracic Surgery, 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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20
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Yan S, Wang X, Wang Y, Lv C, Wang Y, Wang J, Yang Y, Wu N. Intermittent chest tube clamping may shorten chest tube drainage and postoperative hospital stay after lung cancer surgery: a propensity score matching analysis. J Thorac Dis 2017; 9:5061-5067. [PMID: 29312711 DOI: 10.21037/jtd.2017.11.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Postoperative pleural drainage markedly influences the length of hospital stay and the financial costs of medical care. The safety of chest tube clamping before removal has been documented. This study aims to determine if intermittent chest tube clamping shortens the duration of chest tube drainage and hospital stay after lung cancer surgery. Methods We retrospectively analyzed 285 consecutive patients with operable lung cancer treated using lobectomy and systematic mediastinal lymphadenectomy. The chest tube management protocol in our institution was changed in January 2014, and thus, 222 patients (clamping group) were managed with intermittent chest tube clamping, while 63 patients (control group) were managed with a traditional protocol. Propensity score matching at a 1:1 ratio was applied to balance variables potentially affecting the duration of chest tube drainage. Analyses were performed to compare drainage duration and postoperative hospital stay between the two groups in the matched cohort. Multivariate logistic regression analyses were performed to predict the factors associated with chest tube drainage duration. Results The rates of thoracocentesis after chest tube removal were similar between the clamping and control groups in the whole cohort (0.5% vs. 1.6%, P=0.386). The rates of pyrexia were also comparable in the two groups (2.3% vs. 3.2%, P=0.685). After propensity score matching, 61 cases remained in each group. Both chest tube drainage duration (3.9 vs. 4.8 days, P=0.001) and postoperative stay (5.7 vs. 6.4 days, P=0.025) were significantly shorter in the clamping group than in the control group. Factors significantly associated with shorter chest tube drainage duration were female sex, chest tube clamping, left lobectomy, and video-assisted thoracoscopic surgery (VATS) (P<0.05). Conclusions Intermittent postoperative chest tube clamping may decrease the duration of chest tube drainage and postoperative hospital stay while maintaining patient safety.
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Affiliation(s)
- Shi Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xing Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yaqi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Chao Lv
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yuzhao Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jia Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yue Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Nan Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
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21
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Ding M, Gao YD, Zeng XT, Guo Y, Yang J. Endobronchial one-way valves for treatment of persistent air leaks: a systematic review. Respir Res 2017; 18:186. [PMID: 29110704 PMCID: PMC5674238 DOI: 10.1186/s12931-017-0666-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 10/18/2017] [Indexed: 11/10/2022] Open
Abstract
Persistent air leak (PAL) is associated with significant morbidity and mortality, prolonged hospitalization and increased health-care costs. It can arise from a number of conditions, including pneumothorax, necrotizing infection, trauma, malignancies, procedural interventions and complications after thoracic surgery. Numerous therapeutic options, including noninvasive and invasive techniques, are available to treat PALs. Recently, endobronchial one-way valves have been used to treat PAL. We conducted a systematic review based on studies retrieved from PubMed, EMbase and Cochrane library. We also did a hand-search in the bibliographies of relevant articles for additional studies. 34 case reports and 10 case series comprising 208 patients were included in our review. Only 4 patients were children, most of the patients were males. The most common underlying disease was COPD, emphysema and cancer. The most remarkable cause was pneumothorax. The upper lobes were the most frequent locations of air leaks. Complete resolution was gained within less than 24 h in majority of patients. Complications were migration or expectoration of valves, moderate oxygen desaturation and infection of related lung. No death related to endobronchial one-way valves implantation has been found. The use of endobronchial one-way valve adds to the armamentarium for non-invasive treatments of challenging PAL, especially those with difficulties of anesthesia, poor condition and high morbidity. Nevertheless, prospective randomized control trials with large sample should be needed to further evaluate the effects and safety of endobronchial one-way valve implantation in the treatment of PAL.
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Affiliation(s)
- Mei Ding
- Department of Respiratory Medicine, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan, 430071, People's Republic of China
| | - Ya-Dong Gao
- Department of Respiratory Medicine, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan, 430071, People's Republic of China.
| | - Xian-Tao Zeng
- Center for Evidence-based and Translational Medicine, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan, 430071, People's Republic of China
| | - Yi Guo
- Center for Evidence-based and Translational Medicine, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan, 430071, People's Republic of China
| | - Jiong Yang
- Department of Respiratory Medicine, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan, 430071, People's Republic of China
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22
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Carvalho MV, Marchi E, Fruchi AJ, Dias BV, Pinto CL, dos Santos GR, Acencio MM. Local and systemic effects of fibrin and cyanoacrylate adhesives on lung lesions in rabbits. Clinics (Sao Paulo) 2017; 72:624-628. [PMID: 29160425 PMCID: PMC5666443 DOI: 10.6061/clinics/2017(10)06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/18/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Tissue adhesives can be used to prevent pulmonary air leaks, which frequently occur after lung interventions. The objective of this study is to evaluate local and systemic effects of fibrin and cyanoacrylate tissue adhesives on lung lesions in rabbits. METHODS Eighteen rabbits were submitted to videothoracoscopy + lung incision alone (control) or videothoracoscopy + lung incision + local application of fibrin or cyanoacrylate adhesive. Blood samples were collected and assessed for leukocyte, neutrophil and lymphocyte counts and interleukin-8 levels preoperatively and at 48 hours and 28 days post-operatively. After 28 days, the animals were euthanized for gross examination of the lung surface, and lung fragments were excised for histopathological analysis. RESULTS Fibrin and cyanoacrylate produced similar adhesion scores of the lung to the parietal pleura. Microscopic analysis revealed uniform low-cellular tissue infiltration in the fibrin group and an intense tissue reaction characterized by dense inflammatory infiltration of granulocytes, giant cells and necrosis in the cyanoacrylate group. No changes were detected in the leukocyte, neutrophil or lymphocyte count at any time-point, while the interleukin-8 levels were increased in the fibrin and cyanoacrylate groups after 48 hours compared with the pre-operative control levels (p<0.01). CONCLUSION Both adhesive agents promoted normal tissue healing, with a more pronounced local inflammatory reaction observed for cyanoacrylate. Among the serum markers of inflammation, only the interleukin-8 levels changed post-operatively, increasing after 48 hours and decreasing after 28 days to levels similar to those of the control group in both the fibrin and cyanoacrylate groups.
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Affiliation(s)
- Marcus V.H. Carvalho
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
- *Corresponding author. E-mail:
| | - Evaldo Marchi
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
- Laboratorio de Pleura, Divisao Pulmonar, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Andre J. Fruchi
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
| | - Bruno V.B. Dias
- Departamento de Cirurgia Toracica, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
| | - Clovis L. Pinto
- Departamento de Patologia, Faculdade de Medicina de Jundiai, Jundiai, SP, BR
| | | | - Milena M.P. Acencio
- Laboratorio de Pleura, Divisao Pulmonar, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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23
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Gao S, Zhang Z, Aragón J, Brunelli A, Cassivi S, Chai Y, Chen C, Chen C, Chen G, Chen H, Chen JS, Cooke DT, Downs JB, Falcoz PE, Fang W, Filosso PL, Fu X, Force SD, Garutti MI, Gonzalez-Rivas D, Gossot D, Hansen HJ, He J, He J, Holbek BL, Hu J, Huang Y, Ibrahim M, Imperatori A, Ismail M, Jiang G, Jiang H, Jiang Z, Kim HK, Li D, Li G, Li H, Li Q, Li X, Li Y, Li Z, Lim E, Liu CC, Liu D, Liu L, Liu Y, Lobdell KW, Ma H, Mao W, Mao Y, Mou J, Ng CSH, Novoa NM, Petersen RH, Oizumi H, Papagiannopoulos K, Pompili C, Qiao G, Refai M, Rocco G, Ruffini E, Salati M, Seguin-Givelet A, Sihoe ADL, Tan L, Tan Q, Tong T, Tsakiridis K, Venuta F, Veronesi G, Villamizar N, Wang H, Wang Q, Wang R, Wang S, Wright GM, Xie D, Xue Q, Xue T, Xu L, Xu S, Xu S, Yan T, Yu F, Yu Z, Zhang C, Zhang L, Zhang T, Zhang X, Zhao X, Zhao X, Zhi X, Zhou Q. The Society for Translational Medicine: clinical practice guidelines for the postoperative management of chest tube for patients undergoing lobectomy. J Thorac Dis 2017; 9:3255-3264. [PMID: 29221303 PMCID: PMC5708414 DOI: 10.21037/jtd.2017.08.165] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrRP/B <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmH2O depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmH2O] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B).
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Affiliation(s)
- Shugeng Gao
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | | | | | | | - Ying Chai
- Department of Thoracic Surgery, Second Affiliated Hospital, Medical College of Zhejiang University, Hangzhou 310009, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Shanghai 200433, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fujian 350001, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong General Hospital, Guangzhou 510080, China
| | - Haiquan Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai 200030, China
| | - Jin-Shing Chen
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 10002, Taiwan
| | - David Tom Cooke
- Section of General Thoracic Surgery, University of California, Davis Health System, Sacramento, CA, USA
| | - John B. Downs
- Department of Anesthesiology and Critical Care Medicine, University of Florida, Gainesville, FL, USA
| | | | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai 200030, China
| | | | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Seth D. Force
- Cardiothoracic Surgery, Emory University, The Emory Clinic, Atlanta, GA, USA
| | - Martínez I. Garutti
- Department of Anaesthesia and Postoperative Care, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Dominique Gossot
- Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Henrik Jessen Hansen
- Department of Cardiothoracic Surgery, Rigshospitalet (National University Hospital), Copenhagen, Denmark
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
- Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou 510000, China
| | - Jie He
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Bo Laksáfoss Holbek
- Department of Cardiothoracic Surgery and Section for Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jian Hu
- Department of Thoracic Surgery, First Affiliated Hospital, Medical College of Zhejiang University, Hangzhou 310003, China
| | - Yunchao Huang
- Department of Thoracic Surgery, Yunnan Cancer Hospital, Kunming 650100, China
| | - Mohsen Ibrahim
- Division of Thoracic Surgery, Faculty of Medicine and Psychology, Sant’Andrea Hospital, University of Rome ‘Sapienza’, Rome, Italy
| | - Andrea Imperatori
- Center for Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Mahmoud Ismail
- Charité Kompetenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Shanghai 200433, China
| | - Hongjing Jiang
- Department of Esophageal Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China
| | - Zhongmin Jiang
- Department of Thoracic Surgery, Shandong Qianfoshan Hospital, Jinan 250014, China
| | - Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Danqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Beijing 100032, China
| | - Gaofeng Li
- Department of Thoracic Surgery, Yunnan Cancer Hospital, Kunming 650100, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Beijing 100049, China
| | - Qiang Li
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Chengdu 610041, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital Fourth Military Medical University, Xi’an 710038, China
| | - Yin Li
- Henan Cancer Hospital, Zhengzhou 450008, China
| | - Zhijun Li
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Eric Lim
- Imperial College and The Academic Division of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London, UK
| | - Chia-Chuan Liu
- Division of Thoracic Surgery, Department of Surgery, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Deruo Liu
- Department of Thoracic Surgery, China and Japan Friendship Hospital, Beijing 100029, China
| | - Lunxu Liu
- Department of Cardiovascular and Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yongyi Liu
- Department of Thoracic Surgery, Liaoning Cancer Hospital and Institute, Shengyang 110042, China
| | - Kevin W. Lobdell
- Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC, USA
| | - Haitao Ma
- Department of Thoracic Surgery, The First Hospital Affiliated to Soochow University, Suzhou 215000, China
| | - Weimin Mao
- Department of Thoracic Surgery, Zhejiang Cancer Hospital, Hangzhou 310000, China
| | - Yousheng Mao
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Juwei Mou
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Calvin Sze Hang Ng
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, China
| | - Nuria M. Novoa
- Thoracic Surgery Service, University Hospital of Salamanca, Paseo de San Vicente 58-182, 37007 Salamanca, Spain
| | - René H. Petersen
- Department of Cardiothoracic Surgery, Rigshospitalet (National University Hospital), Copenhagen, Denmark
| | - Hiroyuki Oizumi
- Second Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | | | - Cecilia Pompili
- Department of Thoracic Surgery, St. James’s University Hospital, Leeds, UK
- Leeds Institute of Cancer and Pathology, Leeds, UK
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangzhou General Hospital of Guangzhou Military Area Command, Guangzhou 510000, China
| | - Majed Refai
- Thoracic Surgery Department, United Hospitals of Ancona, Via San Vincenzo 5/f Polverigi, Ancona, Italy
| | - Gaetano Rocco
- Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Naples, Italy
| | - Erico Ruffini
- Department of Thoracic Surgery, University of Torino, Torino, Italy
| | - Michele Salati
- Unit of Thoracic Surgery, Ospedali Riuniti Ancona, Ancona, Italy
| | | | - Alan Dart Loon Sihoe
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Lijie Tan
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Qunyou Tan
- Department of Thoracic Surgery, Daping Hospital, Research Institute of Surgery Third Military Medical University, Chongqing 400042, China
| | - Tang Tong
- Department of Thoracic Surgery, Second Affiliated Hospital of Jilin University, Changchun 130041, China
| | - Kosmas Tsakiridis
- Cardiac and Thoracic Department, Private Hospital “St.Lukes”, Thessaloniki, Greece
| | - Federico Venuta
- Department of Surgery “Paride Stefanini” - Thoracic Surgery Unit, Policlinico Umberto I, University of Rome SAPIENZA, Rome, Italy
| | - Giulia Veronesi
- Robotic Surgery, Division of Thoracic Surgery, Humanitas Research Hospital, Via Manzoni 56, Rozzano, Italy
| | | | - Haidong Wang
- Department of Thoracic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
| | - Qun Wang
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Ruwen Wang
- Department of Thoracic Surgery, Daping Hospital, Research Institute of Surgery Third Military Medical University, Chongqing 400042, China
| | - Shumin Wang
- Department of Thoracic Surgery, General Hospital of Shenyang Military Area, Shenyang 110015, China
| | - Gavin M. Wright
- Department of Surgical Oncology, St Vincent’s Hospital, Melbourne, Australia
- Department of Surgery, St Vincent’s Hospital, University of Melbourne, Melbourne, Australia
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Deyao Xie
- Department of Cardiovascular and Thoracic Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Qi Xue
- Department of Thoracic Surgical Oncology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; National Cancer Center, Beijing 100021, China
| | - Tao Xue
- Department of Thoracic Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing 210009, China
| | - Lin Xu
- Department of Thoracic Surgery, Jiangsu Cancer Hospital, Nanjing 210008, China
| | - Shidong Xu
- Department of Thoracic Surgery, Heilongjiang Cancer Hospital, Harbin 150049, China
| | - Songtao Xu
- Department of Thoracic Surgery, Shanghai Zhongshan Hospital of Fudan University, Shanghai 200032, China
| | - Tiansheng Yan
- Department of Thoracic Surgery, Peking University Third Hospital, Beijing 100083, China
| | - Fenglei Yu
- Department of Cardiovascular Surgery, Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Zhentao Yu
- Department of Esophageal Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China
| | - Chunfang Zhang
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Lanjun Zhang
- Cancer Center, San Yat-sen University, Guangzhou 510060, China
| | - Tao Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xinjiang Medical Hospital, Urumqi 830011, China
| | - Xun Zhang
- Department of Thoracic Surgery, Tanjin Chest Hospital, Tianjin 300300, China
| | - Xiaojing Zhao
- Department of Thoracic Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200003, China
| | - Xuewei Zhao
- Department of Thoracic Surgery, Shanghai Changzheng Hospital, Shanghai 200000, China
| | - Xiuyi Zhi
- Department of Thoracic Surgery, Xuanwu Hospital of Capital University of Medical Sciences, Beijing 100053, China
| | - Qinghua Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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24
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Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks. Chest 2017; 152:417-423. [PMID: 28267436 PMCID: PMC6026238 DOI: 10.1016/j.chest.2017.02.020] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 02/07/2017] [Accepted: 02/20/2017] [Indexed: 10/20/2022] Open
Abstract
Alveolar-pleural fistulas causing persistent air leaks (PALs) are associated with prolonged hospital stays and high morbidity. Prior guidelines recommend surgical repair as the gold standard for treatment, albeit it is a solution with limited success. In patients who have recently undergone thoracic surgery or in whom surgery would be contraindicated based on the severity of illness, there has been a lack of treatment options. This review describes a brief history of treatment guidelines for PALs. In the past 20 years, newer and less invasive treatment options have been developed. Aside from supportive care, the literature includes anecdotal successful reports using fibrin sealants, ethanol injection, metal coils, and Watanabe spigots. More recently, larger studies have demonstrated success with chemical pleurodesis, autologous blood patch pleurodesis, and endobronchial valves. This manuscript describes these treatment options in detail, including postprocedural adverse events. Further research, including randomized controlled trials with comparison of these options, are needed, as is long-term follow-up for these interventions.
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Affiliation(s)
- Karen C Dugan
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - Balaji Laxmanan
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - Septimiu Murgu
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - D Kyle Hogarth
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
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25
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Abstract
There is scant evidence on the management of chest tubes after surgery for pneumothorax. Most of the current knowledge is extrapolated from studies performed on subjects with lung cancer. This article reviews the existing literature with particular focus on the effect of suction and no suction on the duration of air leak after lung resection and surgery for pneumothorax. Moreover, the role of regulated suction, which seems to provide some benefit in reducing pneumothorax recurrence after bullectomy and pleurodesis, is discussed. Finally, a personal view on the management of chest tubes after surgery for pneumothorax is provided.
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26
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Abstract
Despite several randomized trials and meta-analyses, the dilemma as to whether to apply suction after subtotal pulmonary resection has not been solved. The combination of a poorly understood pathophysiology of the air leak phenomenon and the inadequate quality of the published randomized trials is actually preventing thoracic surgeons from abandoning an empirical management of chest drains. Even digital systems do not seem to have made the difference so far. Based on the evidence of the literature, the authors propose a new air leak predictor score (ALPS) as a contributing step toward appropriateness in using intraoperative sealants, opting for an external suction and managing and chest tubes.
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27
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Abstract
Insertion, management, and withdrawal of chest tubes is part of the routine activity of thoracic surgeons. The selection of the chest tube and the strategy for each of these steps is usually built on knowledge, practice, experience, and judgment. The indication to insert a chest tube into the pleural cavity is the presence of air or fluid within it. Various types and sizes of chest tubes are now commercially available.
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Affiliation(s)
- Federico Venuta
- Department of Thoracic Surgery, Policlinico Umberto I, University of Rome Sapienza, V.le del Policlinico, Rome, Italy.
| | - Daniele Diso
- Department of Thoracic Surgery, Policlinico Umberto I, University of Rome Sapienza, V.le del Policlinico, Rome, Italy
| | - Marco Anile
- Department of Thoracic Surgery, Policlinico Umberto I, University of Rome Sapienza, V.le del Policlinico, Rome, Italy
| | - Erino A Rendina
- Department of Thoracic Surgery, University of Rome Sapienza, Ospedale S.Andrea, Rome, Italy
| | - Ilaria Onorati
- Department of Thoracic Surgery, Policlinico Umberto I, University of Rome Sapienza, V.le del Policlinico, Rome, Italy
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28
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Igai H, Kamiyoshihara M, Yoshikawa R, Osawa F, Kawatani N, Ibe T, Shimizu K. The efficacy of thoracoscopic fissureless lobectomy in patients with dense fissures. J Thorac Dis 2016; 8:3691-3696. [PMID: 28149565 DOI: 10.21037/jtd.2016.12.58] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prolonged air leakage after a lobectomy remains a frequent complication in patients with dense fissures. To avoid postoperative air leakage, we used the "thoracoscopic fissureless technique" for patients with dense fissures. A thoracoscopic approach is useful for the fissureless technique because it gives a good operative view from various angles without dividing the fissure. In this study, we compared the peri- or intraoperative results of thoracoscopic fissureless lobectomies to traditional lobectomies with fissure dissection for pulmonary artery (PA) exposure in order to identify the efficacy of thoracoscopic fissureless lobectomy. METHODS Between April 2012 and November 2015, 175 patients underwent a thoracoscopic lobectomy with three or four ports, of whom 14 underwent a fissureless lobectomy because of dense fissures. We compared the characteristics and perioperative outcomes of the patients who underwent the fissureless technique (fissureless technique group, n=14) and the traditional fissure dissection technique for PA exposure (traditional technique group, n=161). In our department, fissureless lobectomy is indicated for patients with a fused fissure (fissural grade III or IV as proposed by Craig in 1997) or inflammation makes it difficult to expose the PA, while the traditional technique is used for other patients. RESULTS Although the fissureless technique group had longer operation time than the traditional technique group (P=0.0045), there was no significant inter-group difference about blood loss (P=0.85), occurrence rate of intraoperative massive bleeding (P=0.6) or conversion rate to thoracotomy (P=0.31). According to postoperative results, there was no significant inter-group difference in duration of chest tube drainage (P=0.56), length of postoperative hospital stay (P=0.14), or morbidity rate (P=0.16). No mortality occurred in either group. CONCLUSIONS A thoracoscopic fissureless lobectomy is feasible and safe, and useful to avoid postoperative air-leakage in patients with dense fissures.
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Affiliation(s)
- Hitoshi Igai
- Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Japan
| | | | - Ryohei Yoshikawa
- Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Fumi Osawa
- Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Natsuko Kawatani
- Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Takashi Ibe
- Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Japan
| | - Kimihiro Shimizu
- Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
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29
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Comparison of Suction Versus Nonsuction Drainage After Lung Resections: A Prospective Randomized Trial. Ann Thorac Surg 2016; 102:1119-24. [DOI: 10.1016/j.athoracsur.2016.04.066] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 04/11/2016] [Accepted: 04/11/2016] [Indexed: 11/19/2022]
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30
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Numan RC, Berge MT, Burgers JA, Klomp HM, van Sandick JW, Baas P, Wouters MW. Peri- and postoperative management of stage I-III Non Small Cell Lung Cancer: Which quality of care indicators are evidence-based? Lung Cancer 2016; 101:129-136. [PMID: 27794401 DOI: 10.1016/j.lungcan.2016.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/30/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
Abstract
Quality of care (QoC) has a central role in our health care system. The aim of this review is to present a set of evidence-based quality indicators for the surgical treatment and postoperative management of lung cancer. A search was performed through PubMed, Embase and the Cochrane library database, including English literature, published between 1980 and 2012. Search terms regarding 'lung neoplasms', 'surgical treatment' and 'quality of care' were used. Potential QoC indicators were divided into structure, process or outcome measures and a final selection was made based upon the level of evidence. High hospital volume and surgery performed by a thoracic surgeon, were identified as important structure indicators. Sleeve resection instead of pneumonectomy and the importance of treatment within a clinical care path setting were identified as evidence-based process indicators. A symptom-based follow-up regime was identified as a new QoC indicator. These indicators can be used for registration, benchmarking and ultimately quality improvement in lung cancer surgery.
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Affiliation(s)
- Rachel C Numan
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands.
| | - Martijn Ten Berge
- Department of Surgical Oncology, Leids Universitair Medisch Centrum, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jacobus A Burgers
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Houke M Klomp
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Paul Baas
- Department of Thoracic Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
| | - Michel W Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Plesmanlaan 161, 1066CX Amsterdam, The Netherlands
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31
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Ishibashi H, Kobayashi M, Takasaki C, Ishikawa S, Miura Y, Makita K, Okubo K. Efficacy of Supraglottic Airway for Preventing Lung Injury Associated with Coughing at Extubation after Pulmonary Lobectomy. World J Surg 2016; 40:1892-8. [PMID: 27160455 DOI: 10.1007/s00268-016-3522-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of double-lumen endobronchial tubes (DLTs) is necessary for differential lung ventilation during pulmonary lobectomy. However, when used with conventional extubation procedures, coughing is more likely and is associated with an increased risk for parenchymal air leak along the staple line and possible subsequent lung injury. We examined the prevalence of coughing-associated air leaks at extubation and the efficacy of using supraglottic airways (SGAs) to prevent air leaks with post-lobectomy extubation. METHODS This study included 150 patients with pulmonary emphysema diagnosed using preoperative computed tomography, who underwent pulmonary lobectomy between April 2010 and March 2015. The patients were chronologically enrolled in two groups: the DLT group (60 patients) from April 2010 to August 2012, and the SGA group (90 patients) from September 2012 to March 2015. (Note: the DLT group only included cases without air leak present just prior to extubation). Data were collected on specific patient characteristics and operative and postoperative factors. RESULTS Coughing at extubation occurred in 15 (25.0 %) of 60 DLT patients, and parenchymal air leaks developed in 10 (66.7 %) of these 15. Comparison of groups revealed the SGA group was significantly lower for the following: patients with coughing at extubation (P < 0.001), coughing-associated air leaks at extubation (P < 0.001), air leaks >7 days (P = 0.006), reoperation due to air leaks (P = 0.013), and duration of chest tube drainage (P < 0.001). CONCLUSIONS The SGA is effective for preventing air leaks associated with coughing during conventional DLT extubation in post-lobectomy patients.
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Affiliation(s)
- Hironori Ishibashi
- Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Masashi Kobayashi
- Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Chihiro Takasaki
- Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Seiji Ishikawa
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yutaka Miura
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Koshi Makita
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kenichi Okubo
- Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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32
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Intrabronchial Valve Treatment for Prolonged Air Leak: Can We Justify the Cost? Can Respir J 2016; 2016:2867547. [PMID: 27445523 PMCID: PMC4904513 DOI: 10.1155/2016/2867547] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 03/09/2016] [Indexed: 11/18/2022] Open
Abstract
Background. Prolonged air leak is defined as an ongoing air leak for more than 5 days. Intrabronchial valve (IBV) treatment is approved for the treatment of air leaks. Objective. To analyze our experience with IBV and valuate its cost-effectiveness. Methods. Retrospective analysis of IBV from June 2013 to October 2014. We analyzed direct costs based on hospital and operating room charges. We used average costs in US dollars for the analysis not individual patient data. Results. We treated 13 patients (9 M/4 F), median age of 60 years (38 to 90). Median time from diagnosis to IBV placement was 9.8 days, time from IBV placement to chest tube removal was 3 days, and time from IBV placement to hospital discharge was 4 days. Average room and board costs were $14,605 including all levels of care. IBV cost is $2750 per valve. The average number of valves used was 4. Total cost of procedure, valves, and hospital stay until discharge was $13,900. Conclusion. In our limited experience, the use of IBV to treat prolonged air leaks is safe and appears cost-effective. In pure financial terms, the cost seems justified for any air leak predicted to last greater than 8 days.
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French DG, Dilena M, LaPlante S, Shamji F, Sundaresan S, Villeneuve J, Seely A, Maziak D, Gilbert S. Optimizing postoperative care protocols in thoracic surgery: best evidence and new technology. J Thorac Dis 2016; 8:S3-S11. [PMID: 26941968 DOI: 10.3978/j.issn.2072-1439.2015.10.67] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Postoperative clinical pathways have been shown to improve postoperative care and decrease length of stay in hospital. In thoracic surgery there is a need to develop chest tube management pathways. This paper considers four aspects of chest tube management: (I) appraising the role of chest X-rays in the management of lung resection patients with chest drains; (II) selecting of a fluid output threshold below which chest tubes can be removed safely; (III) deciding whether suction should be applied to chest tubes; (IV) and selecting the safest method for chest tube removal. There is evidence that routine use of chest X-rays does not influence the management of chest tubes. There is a lack of consensus on the highest fluid output threshold below which chest tubes can be safely removed. The optimal use of negative intra-pleural pressure has not yet been established despite multiple randomized controlled trials and meta-analyses. When attempting to improve efficiency in the management of chest tubes, evidence in support of drain removal without a trial of water seal should be considered. Inconsistencies in the interpretation of air leaks and in chest tube management are likely contributors to the conflicting results found in the literature. New digital pleural drainage systems, which provide a more objective air leak assessment and can record air leak trend over time, will likely contribute to the development of new evidence-based guidelines. Technology should be combined with continued efforts to standardize care, create clinical pathways, and analyze their impact on postoperative outcomes.
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Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Michael Dilena
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Simon LaPlante
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Farid Shamji
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Sudhir Sundaresan
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - James Villeneuve
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Andrew Seely
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Donna Maziak
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
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Abstract
An adequate chest drainage system aims to drain fluid and air and restore the negative pleural pressure facilitating lung expansion. In thoracic surgery the post-operative use of the conventional underwater seal chest drainage system fulfills these requirements, however they allow great variability amongst practices. In addition they do not offer accurate data and they are often inconvenient to both patients and hospital staff. This article aims to simplify the myths surrounding the management of chest drains following chest surgery, review current experience and explore the advantages of modern digital chest drain systems and address their disease-specific use.
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Podgaetz E, Andrade RS, Zamora F, Gibson H, Dincer HE. Endobronchial Treatment of Bronchopleural Fistulas by Using Intrabronchial Valve System: A Case Series. Semin Thorac Cardiovasc Surg 2015; 27:218-22. [PMID: 26686450 DOI: 10.1053/j.semtcvs.2015.06.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2015] [Indexed: 11/11/2022]
Abstract
Air leaks, alveolopleural or bronchopleural fistulas, either spontaneous, iatrogenic, or postsurgical, can be difficult to treat, and if prolonged in spite of proper chest tube thoracostomy they may require surgical or chemical pleurodesis with variable success. Intrabronchial valve (IBV) treatment is minimally invasive and has a potential to shorten the duration of air leaks in well-selected patients with ongoing air leaks. The study included 19 patients with prolonged air leaks treated with IBVs spiration, with a total of 71 valves placed at a tertiary university hospital. Internal Board Review approval was obtained to use IBVs for off-label indication. IBVs were placed in desired airways with 100% accuracy in patients with air leaks without complications, including self-migration. All 19 patients with air leaks were initially treated with chest tube thoracostomy and in addition chemical pleurodesis in 2 and blood patch in a patient without success. After IBV placement, all patients but one with air leak had successful resolution of the air leak and removal of chest tube in a median of 3 days (range: 2-45 days). In conclusion, the use of IBVs for prolonged air leaks in various etiologies is effective and safe.
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Affiliation(s)
- Eitan Podgaetz
- Division of Cardiothoracic Surgery, Section of Thoracic and Foregut Surgery, University of Minnesota, Minneapolis, Minnesota.
| | - Rafael S Andrade
- Division of Cardiothoracic Surgery, Section of Thoracic and Foregut Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Felix Zamora
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heidi Gibson
- Cardiopulmonary Service, University of Minnesota, Minneapolis, Minnesota
| | - H Erhan Dincer
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota
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Lang P, Manickavasagar M, Burdett C, Treasure T, Fiorentino F. Suction on chest drains following lung resection: evidence and practice are not aligned. Eur J Cardiothorac Surg 2015; 49:611-6. [PMID: 25870218 DOI: 10.1093/ejcts/ezv133] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 03/04/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES A best evidence topic in Interactive CardioVascular and Thoracic Surgery (2006) looked at application of suction to chest drains following pulmonary lobectomy. After screening 391 papers, the authors analysed six studies (five randomized controlled trials [RCTs]) and found no evidence in favour of postoperative suction in terms of air leak duration, time to chest drain removal or length of stay. Indeed, suction was found to be detrimental in four studies. We sought to determine whether clinical practice is consistent with published evidence by surveying thoracic units nationally and performing a meta-analysis of current best evidence. METHODS We systematically searched MEDLINE, EMBASE and CENTRAL for RCTs, comparing outcomes with and without application of suction to chest drains after lung surgery. A meta-analysis was performed using RevMan(©) software. A questionnaire concerning chest drain management and suction use was emailed to a clinical representative in every thoracic unit. RESULTS Eight RCTs, published 2001-13, with 31-500 participants, were suitable for meta-analysis. Suction prolonged length of stay (weighted mean difference [WMD] 1.74 days; 95% confidence interval [CI] 1.17-2.30), chest tube duration (WMD 1.77 days; 95% CI 1.47-2.07) and air leak duration (WMD 1.47 days; 95% CI 1.45-2.03). There was no difference in occurrence of prolonged air leak. Suction was associated with fewer instances of postoperative pneumothorax. Twenty-five of 39 thoracic units responded to the national survey. Suction is routinely used by all surgeons in 11 units, not by any surgeon in 5 and by some surgeons in 9. Of the 91 surgeons represented, 62 (68%) routinely used suction. Electronic drains are used in 15 units, 10 of which use them routinely. CONCLUSIONS Application of suction to chest drains following non-pneumonectomy lung resection is common practice. Suction has an effect in hastening the removal of air and fluid in clinical experience but a policy of suction after lung resection has not been shown to offer improved clinical outcomes. Clinical practice is not aligned with Level 1a evidence.
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Affiliation(s)
- Peter Lang
- Department of Cardiac Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Menaka Manickavasagar
- Department of Cardiac Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Clare Burdett
- Cambridge Centre for Cardiovascular Research Excellence, Cambridge, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - Francesca Fiorentino
- Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College London, London, UK
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Negative pleural suction in thoracic trauma patients: A randomized controlled trial. J Trauma Acute Care Surg 2014; 77:251-5. [PMID: 25058250 DOI: 10.1097/ta.0000000000000281] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The study aimed to establish the benefits of using chest tubes with negative pleural suction against trapped water in patients with penetrating or blunt chest trauma who underwent tube thoracostomy, in terms of the incidence of complications, such as persistent air leak, clotted hemothorax, empyema, and duration of stay. METHODS Patients who underwent tube thoracostomy because of traumatic pneumothorax, hemothorax, or hemopneumothorax were randomly assigned into one of two groups: in Group 1, the three-bottle drainage system was connected to a negative suction; in Group 2, no suction was given. Patients who required mechanical ventilation or emergency surgery (thoracotomy or thoracoscopy) either at the time of admission to the institution or immediately after the tube thoracostomy, patients who had histories of thoracic procedures or chronic pulmonary diseases (chronic obstructive pulmonary disease, diffuse interstitial lung disease), and patients with multiple injuries with severe traumatic brain injury and a Glasgow Coma Scale (GCS) score less than 8 of 15 were excluded from the study. Hospital stay, duration of tube thoracostomy, prolonged fistula, and other clinical variables were compared. RESULTS One hundred ten patients were included, 56 in the group with suction and 54 in the group without suction. There were no differences in the demographic characteristics of each group. There were no differences between the groups in terms of hospital stay (p = 0.22), duration of tube thoracostomy (p = 0.35) (3 days in each group), or complications. However, the probability of air leak presence in time was greater for the Group 1 patients with negative suction versus the Group 2 patients (p = 0.023). CONCLUSION The use of negative pleural suction did not demonstrate advantages over the three-bottle chest drainage system without suction in patients with uncomplicated traumatic pneumothorax, hemothorax, or hemopneumothorax. LEVEL OF EVIDENCE Therapeutic study, level II.
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Mueller MR, Marzluf BA. The anticipation and management of air leaks and residual spaces post lung resection. J Thorac Dis 2014; 6:271-84. [PMID: 24624291 DOI: 10.3978/j.issn.2072-1439.2013.11.29] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 11/27/2013] [Indexed: 11/14/2022]
Abstract
The incidence of any kind of air leaks after lung resections is reportedly around 50% of patients. The majority of these leaks doesn't require any specific intervention and ceases within a few hours or days. The recent literature defines a prolonged air leak (PAL) as an air leak lasting beyond postoperative day 5. PAL is associated with a generally worse outcome with a more complicated postoperative course anxd prolonged hospital stay and increased costs. Some authors therefore consider any PAL as surgical complication. PAL is the most prevalent postoperative complication following lung resection and the most important determinant of postoperative length of hospital stay. A low predicted postoperative forced expiratory volume in 1 second (ppoFEV1) and upper lobe disease have been identified as significant risk factors involved in developing air leaks. Infectious conditions have also been reported to increase the risk of PAL. In contrast to the problem of PAL, there is only limited information from the literature regarding apical spaces after lung resection, probably because this common finding rarely leads to clinical consequences. This article addresses the pathogenesis of PAL and apical spaces, their prediction, prevention and treatment with a special focus on surgery for infectious conditions. Different predictive models to identify patients at higher risk for the development of PAL are provided. The discussion of surgical treatment options includes the use of pneumoperitoneum, blood patch, intrabronchial valves (IBV) and the flutter valve, and addresses the old question, whether or not to apply suction to chest tubes. The discussed prophylactic armentarium comprises of pleural tenting, prophylactic intraoperative pneumoperitoneum, sealing of the lung, buttressing of staple lines, capitonnage after resection of hydatid cysts, and plastic surgical options.
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Affiliation(s)
- Michael Rolf Mueller
- Otto Wagner Hospital, Department of Thoracic Surgery, Baumgartner Hoehe 1, A-1145 Vienna, Austria
| | - Beatrice A Marzluf
- Otto Wagner Hospital, Department of Thoracic Surgery, Baumgartner Hoehe 1, A-1145 Vienna, Austria
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Leo F, Duranti L, Girelli L, Furia S, Billè A, Garofalo G, Scanagatta P, Giovannetti R, Pastorino U. Does External Pleural Suction Reduce Prolonged Air Leak After Lung Resection? Results From the AirINTrial After 500 Randomized Cases. Ann Thorac Surg 2013; 96:1234-1239. [DOI: 10.1016/j.athoracsur.2013.04.079] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 04/15/2013] [Accepted: 04/29/2013] [Indexed: 11/25/2022]
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Qiu T, Shen Y, Wang MZ, Wang YP, Wang D, Wang ZZ, Jin XF, Wei YC. External suction versus water seal after selective pulmonary resection for lung neoplasm: a systematic review. PLoS One 2013; 8:e68087. [PMID: 23874505 PMCID: PMC3706622 DOI: 10.1371/journal.pone.0068087] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/25/2013] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate whether external suction is more advantageous than water seal in patients undergoing selective pulmonary resection (SPR) for lung neoplasm. Summary of Background Data Whether external suction should be routinely applied in postoperative chest drainage is still unclear, particularly for lung neoplasm patients. To most surgeons, the decision is based on their clinical experience. Methods Randomized control trials were selected. The participants were patients undergoing SPR with lung neoplasm. Lung volume reduction surgery and pneumothorax were excluded. Suction versus non-suction for the intervention. The primary outcome was the incidence of persistent air leak (PAL). The definition of PAL was air leak for more than 3–7 days. The secondary outcomes included air leak duration, time of drainage, postoperative hospital stay and the incidence of postoperative pneumothorax. Studies were identified from literature collections through screening. Bias was analyzed and meta-analysis was used. Results From the 1824 potentially relevant trials, 6 randomized control trials involving 676 patients were included. There was no difference between external suction and water seal in decreasing the incidence of PAL [95% confidence interval (CI) 0.81−2.16; z = 1.10; P = 0.27]. Regarding secondary outcomes, there were no differences in time of drainage (95% CI−0.36−1.56, P = 0.22), postoperative hospital stay (95% CI -.31−.54, P = 0.87) or incidence of postoperative pneumothorax (95% CI 0.18−.02, P = 0.05) between external suction and water seal. Conclusions For participants, no differences are identified in terms of PAL incidence, drainage time, length of postoperative hospital stay or incidence of postoperative pneumothorax between external suction and water seal. The bias analysis should be emphasized. To the limitations of the bias and methodological differences among the included studies, we have no recommendation on whether external suction should be routinely applied after lung neoplasm SPR. More high-quality randomized controlled trials are needed. Systematic Review Registration None.
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Affiliation(s)
- Tong Qiu
- Department of Thoracic Surgery, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, China
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Hawley D, Gunn S, Elliott R. The clinical effectiveness of suction versus water seal for optimal management of pleural chest tubes in adult patients: A systematic review protocol. ACTA ACUST UNITED AC 2013. [DOI: 10.11124/jbisrir-2013-989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Coughlin SM, Emmerton-Coughlin HMA, Malthaner R. Management of chest tubes after pulmonary resection: a systematic review and meta-analysis. Can J Surg 2012; 55:271-4. [PMID: 22854148 DOI: 10.1503/cjs.001411] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We performed a systematic review and meta-analysis to determine the effect of suction with water seal, compared with water seal alone, applied to intra pleural chest tubes on the duration of air leaks in patients undergoing pulmonary surgery. METHODS We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to find randomized controlled trials (RCTs) comparing the effect of the 2 methods on the duration of air leaks. Trials were systematically assessed for eligibility and validity. Data were extracted in duplicate and pooled across studies using a random-effects model. RESULTS The search yielded 7 RCTs that met the eligibility criteria. No difference was identified between the 2 methods in duration of air leak (weighted mean difference [WMD] 1.15 days, favours water seal; 95% confidence interval [CI] -0.64 to 2.94), time to discharge (WMD 2.19 d, favours water seal; 95% CI -0.63 to 5.01), duration of chest tubes (WMD 0.96 d, favours water seal; 95% CI -0.12 to 2.05) or incidence of prolonged air leaks (absolute risk reduction [ARR] 0.04, favours water seal; 95% CI -0.01 to 0.09). Water seal was associated with a significantly increased incidence of postoperative pneumothorax (ARR -0.14, 95% CI -0.21 to -0.07). CONCLUSION No differences were identified in terms of duration of air leak, incidence of prolonged air leak, duration of chest tubes and duration of hospital stay when chest tubes were placed to suction rather than water seal. Chest tube suction appears to be superior to water seal in reducing the incidence of pneumothorax; however, the clinical significance of this finding is unclear.
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Affiliation(s)
- Shaun M Coughlin
- The Department of Surgery, University of Western Ontario, London, Ont
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Brunelli A, Salati M, Pompili C, Refai M, Sabbatini A. Regulated tailored suction vs regulated seal: a prospective randomized trial on air leak duration†. Eur J Cardiothorac Surg 2012; 43:899-904. [DOI: 10.1093/ejcts/ezs518] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Comparative study of lung sealants in a porcine ex vivo model. Ann Thorac Surg 2012; 94:234-40. [PMID: 22560324 DOI: 10.1016/j.athoracsur.2012.03.050] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 03/16/2012] [Accepted: 03/21/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Lung sealants are often used to prevent alveolar air leaks after lung resection surgery. Some sealants have shown to be effective in clinical studies, but extensive comparative evaluation has not yet been conducted. We aimed to evaluate different sealant burst pressures in an ex vivo model mimicking air leakage after lung resection. METHODS Fifty-four porcine lungs comprised the study material. Six different sealants were evaluated: Bioglue (V-Tech, Roskilde, Denmark), TachoSil (Nycomed, Roskilde, Denmark), Tisseel (Baxter, Allerød, Denmark), Evicel (OMRIX biopharmaceuticals S.A, Rhode-St-Genèse, Belgium), TissuePatchDural (Vingmed, Roskilde, Denmark), and Pleuraseal (Covidien, Copenhagen, Denmark). After creating a standardized pleural defect, each lung was randomized into 1 of the 6 treatment groups (n= 9). Each lung was ventilated with incremental airway pressure. Air leakage was assessed after each increment. If leakage occurred, the burst pressure was recorded. RESULTS The Evicel fibrin sealant and Tisseel fibrin sealant exhibited significantly lower burst pressures compared with the Bioglue, TachoSil, and Pleuraseal (p < 0.05). Bioglue had the highest median burst pressure (55 cm H(2)O) followed by TachoSil (35 cm H(2)O), PleuraSeal (35 cm H(2)O), TissuePatchDural (25 cm H(2)O), Evicel (15 cm H(2)O), and Tisseel (15 cm H(2)O). CONCLUSIONS This model has shown to be feasible in determining and comparing the burst pressures of different lung sealants. Further studies are needed to determine responses in living tissue and burst pressure over time in vivo.
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Taves DR. Rank-Minimization with a two-step analysis should replace randomization in clinical trials. J Clin Epidemiol 2012; 65:3-6. [DOI: 10.1016/j.jclinepi.2011.06.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 06/10/2011] [Accepted: 06/13/2011] [Indexed: 10/15/2022]
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Rathinam S, Bradley A, Cantlin T, Rajesh PB. Thopaz Portable Suction Systems in Thoracic Surgery: an end user assessment and feedback in a tertiary unit. J Cardiothorac Surg 2011; 6:59. [PMID: 21510897 PMCID: PMC3094380 DOI: 10.1186/1749-8090-6-59] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 04/21/2011] [Indexed: 11/10/2022] Open
Abstract
Background Thoracic surgical patients have chest drains inserted to enable re-expansion of lungs, to clear contents from the pleural cavity which sometimes require negative suction. Suction impedes mobility, may have variable suction delivery and increases risk of infection. Assessment of air-leak in conventional drains is not scientific and is subjective. Thopaz chest drain system is a portable suction unit which allows mobilization of the patient, with scientific digital flow recordings and an in built alarm system. Methods We evaluated the utility, staff and patient feedback of this device in a pilot evaluation in a regional thoracic unit in a structured format over a period of two months. Staff responses were graded on a scale of 1 to 6 [1 Excellent to 6 Poor]. Results 120 patients who underwent elective bullectomy/pleurectomy, VATS lung biopsies, VATS metastectomy and lung resections were evaluated. The staff feedback forms were positive. The staff liked the system as it was more scientific and accurately recordable. It made nursing and physiotherapy easier as they could mobilise patients early. The patients liked the compact design, weightlessness and the silence. It enabled mobilisation of the patients and scientific removal of chest drain. Conclusions Thopaz digital suction units were found to be user friendly and were liked by the staff and patients. The staff feedback stated the devices to be objective and scientific in making decisions about removal and enabled mobilisation.
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Affiliation(s)
- Sridhar Rathinam
- Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK
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Shi H, Mei L, Che G. [The current concepts of closed chest drainage in lobectomy of lung cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2011; 13:999-1003. [PMID: 21081037 PMCID: PMC6000497 DOI: 10.3779/j.issn.1009-3419.2010.11.01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
肺叶切除术后应用传统胸腔闭式引流术,被大多数胸外科医生所采用的主要原因:一是引流效果好;二是经验、习惯和观念。外科技术的发展和医疗观念的更新使传统胸腔闭式引流术在临床应用中的不足越来越明显,但尚未引起足够重视。近几年对肺癌术后引流问题无论是应用方法还是观念都有更新和发展。本文将结合国内外研究进展和我们工作中的体会,从以下三方面进行概述:一是胸腔引流术应用现状和存在问题;二是常规水封引流系统加用负压吸引之优势与不足;三是单胸腔引流管的临床应用进展与争议。
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Affiliation(s)
- Hui Shi
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Simón Adiego C, Alonso SA, Gutiérrez EC, Martínez EP. Complicaciones quirúrgicas de la resección pulmonar. Arch Bronconeumol 2011; 47 Suppl 8:26-31. [DOI: 10.1016/s0300-2896(11)70064-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Merritt RE, Singhal S, Shrager JB. Evidence-based suggestions for management of air leaks. Thorac Surg Clin 2010; 20:435-48. [PMID: 20619236 DOI: 10.1016/j.thorsurg.2010.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The management of postoperative alveolar air leaks (AALs) continues to challenge thoracic surgeons. AALs increase length of stay and health care costs, and likely lead to other postoperative complications. Staple line buttresses, topical sealants, pleural tents, pneumoperitoneum, and modifications of traditional chest tube management (ie, reduced suction) have all been proposed to help reduce AAL. However, the cost of some of the commercial products being marketed may outweigh their relative effectiveness, and some of these techniques and products have not been adequately studied to date. This article provides a review of the available evidence-based literature that addresses the efficacy of the options currently available to prevent and manage AALs. Management suggestions based on this literature are presented.
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Affiliation(s)
- Robert E Merritt
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford Medical Center, 2nd floor Falk Building, 300 Pasteur Drive, Stanford, CA 94305, USA.
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