Timing of Chest Tube Removal Following Adult Cardiac Surgery: A Cluster Randomized Controlled Trial

OBJECTIVES

Early chest tube removal following cardiac surgery may be associated with an increased risk of pleural or pericardial effusions following cardiac surgery. This study compares the effects of two fast-track chest tube removal protocols regarding the risk of pleural or pericardial effusions, requirement of opioids, respiratory function, and postoperative complications.

DESIGN

Prospective non-blinded cluster-randomized study with alternating chest tube removal protocol in adult patients undergoing elective cardiac surgery. Monthly changing allocation to scheduled chest tube removal on the day of surgery (Day 0) versus removal on the 1st postoperative day (Day 1) provided no air leakage and output < 200 mL within the last four hours.

RESULTS

A total of 527 patients were included in the study from September 1st 2020 until October 29th 2021 and randomly allocated to chest tube removal at day 0 (n = 255), and day 1 (n = 272). More than every fourth patient required drainage for pleural effusion with no significant difference between the groups. Earlier removal of chest tubes did not reduce requirement of analgesics, improve early respiratory function, or reduce postoperative complications. The study was halted for futility after halfway interim analysis showed insufficient promise of any treatment benefit.

CONCLUSION

Fast-track protocols with chest tube removal within the first 24 h after cardiac surgery may be associated a high rate of pleural effusions.

Comparison of surgical outcomes after robotic assisted thoracic surgery, video-assisted thoracic surgery and open resection of thymoma

Background

Thymomas are the most common neoplasm in the anterior mediastinum. Surgical resection of thymomas remains the only curative treatment depending on the stage of the disease. Conventional resection has been performed through open surgery. However, minimal invasive and robotic assisted surgery are preferred if possible.

Methods

In a single center study three different surgical techniques were compared respectively, video-assisted thoracic surgery (VATS), robotic-assisted thoracic surgery (RATS) and open resection. In a period from 2006 to 2019 80 patients were included in the study and data were collected by retrospectively reviewing patient records.

Results

VATS and RATS had a significantly (P<0.05) shorter time with chest tube and shorter admission time compared to open surgery. Furthermore, VATS and RATS had significantly (P<0.05) lower blood loss per operatively compared to open surgery. There was no significant difference in operating time between the three groups.

Conclusions

Minimal invasive surgery seems to be a safe surgical method in the treatment of thymomas. RATS and VATS were associated with a lower blood loss through surgery, shorter admission time and shorter chest tube time compared to open resection. RATS surgery might be considered for patients with a more advanced thymoma stage. Larger international multicenter randomized controlled trials are required to draw any conclusions regarding the oncological point of view.

A case of severe flail chest with several dislocated sterno-chondral fractures

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Surgical stabilization of flail chest lead to fast weaning from mechanical ventilation.

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Plates can be used for stabilization of sterno-costal dehiscence.

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Cartilage reconstruction of a CT scan can reveal the true severity of the trauma.

Introduction

Flail chest is diagnosed clinically by the presence of paradox movement of a segment of the thoracic wall during spontaneous breathing. Radiographic finding confirming a clinical flail chest are fractures of three or more consecutive ribs or costal cartilages in two or more places. Surgical stabilization is associated with a reduced length of hospital stay, time with mechanical ventilation and risk of respiratory complications.

Presentation of case

A trauma patient had a Computed Tomography (CT) scan showing multiple costa fractures, sternal fracture, manubrium fracture, sternal displacement and dehiscence of the sternal-costal attachment. The severity of the trauma was visualized after performing a cartilage reconstruction of the trauma CT scan. The patient underwent surgery, using fixation plates to stabilize the thoracic cage, and was then weaned quickly from mechanical ventilation.

Discussion

This case indicates, that if a patient has a severe flail chest recognized clinically, but not radiologically, a reconstruction of cartilage can reveal the true severity of the trauma. Indeed, the patient in this case experienced a positive outcome from surgery. However, such a procedure demands correct timing and experience in surgical stabilization of the thoracic wall. Furthermore, the injury required accurate planning with the involved personal before surgery.

Conclusion

Surgical stabilization of advanced flail chest with concomitant sternal fracture, seems to be a safe procedure, that might reduce the need of mechanical ventilation and the length of stay at the Intensive Care Unit (ICU). Furthermore, cartilage reconstruction of the trauma CT scan can potentially identify a severe flail chest, that might be missed on regular 3D bone reconstruction.

[Saphenous vein harvesting techniques for coronary artery bypass grafting]

The saphenous vein is a frequently used graft material in coronary artery bypass grafting. In this review, three harvesting techniques are presented, and their benefits and disadvantages are discussed. Endoscopic harvesting (EVH) has reduced harvest site complications. The method is safe in terms of mortality, myocardial infarction and revascu-larisation frequency compared with open vein harvesting. A recent meta-analysis recommends EVH as first of choice. The no-touch technique has shown a tendency towards increased graft patency, however, further studies are needed in comparing this technique with EVH.

Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis

Achilles tendon ruptures can be either surgically or conservatively treated with either early functional mobilization or cast immobilization. The purpose of the present study was to conduct a meta-analysis comparing the effect of early versus late weightbearing in conservatively treated adult patients, including only randomized controlled trials (RCTs). The primary endpoint was rerupture, and the secondary endpoints were strength, quality of life during treatment, range of motion, deep venous thrombosis, return to sports, and return to work. The search for studies was conducted using PubMed, EMBASE, and the Cochrane Central Register of Controlled trials. A search was performed, and 2 reviewers independently screened the studies by title, abstract, and, finally, by reading the full text. Four studies met the inclusion criteria. The reference lists of the included studies were scanned and 1 additional RCT study was included. The critical appraisal skills program checklist was applied for study appraisal. A statistician performed the data management and analysis. No statistically significant differences were found between the 2 treatment groups concerning rerupture (p = .796), return to sports (p = .455), or return to work (p = .888). One RCT found 1 case of deep venous thrombosis in the late weightbearing group. One RCT reported significant improvement in quality of life and one reported a significantly improved range of dorsiflexion in the early weightbearing group. No statistically significant difference was found between early and late weightbearing with conservative treatment regarding the rerupture rate. The results of the other outcomes were limited by the low number of studies included in the present meta-analysis. Larger randomized studies are needed to investigate these outcomes. From the results in the present study, we would recommend early weightbearing when an Achilles tendon rupture is treated conservatively.