Eur J Cardiothorac Surg 2004;25:872-876
© 2004 Elsevier Science NL
Avoiding chest tube placement after video-assisted thoracoscopic wedge resection of the lung
Atsushi Watanabe*,
Toshiaki Watanabe,
Hisayoshi Ohsawa,
Tohru Mawatari,
Yasunori Ichimiya,
Noriyuki Takahashi,
Hiroki Sato,
Tomio Abe
Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan
Received 27 November 2003;
received in revised form 21 January 2004;
accepted 28 January 2004.
* Corresponding author. Tel.: +81-11-611-2111x3312; fax: +81-11-613-7318
e-mail: atsushiw{at}sapmed.ac.jp
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Abstract
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Objective: A chest tube is usually placed in the pleural cavity after wedge resection of the lung, even after thoracoscopic procedures. The aim of this study was to determine the validity and safety of postoperative management without chest tube placement for patients undergoing thoracoscopic wedge resection of the lung. Methods: Between 1998 and 2002, 93 patients underwent thoracoscopic wedge resection of the lung. In January 2000, we established the following criteria for avoiding chest tube placement: (1) absence of air leaks during intraoperative alternative sealing test, (2) absence of bullous or emphysematous changes on inspection, (3) absence of severe pleural adhesions, and (4) absence of prolonged pleural effusion requiring chest drainage preoperatively. Seventeen of 93 patients did not satisfy the criteria. The other 76 patients were divided into two groups: group 1 consisted of 34 patients who underwent thoracoscopic resection before 1999 and in whom a chest tube was routinely placed in spite of retrospectively meeting the criteria, group 2 consisted of 42 patients who underwent thoracoscopic resection after 2000 and in whom chest tube was not placed. The clinical data were evaluated and analyzed between the two groups. Results: Two patients in group 1 required new intervention after removal of a chest tube that had been inserted during the operation due to recurrence of a pneumothorax, so did two patients in group 2 after the operation. The rate of late pneumothorax requiring intervention is similar in groups 1 and 2. No differences were found between the two groups with regard to postoperative chest pain and hospital stay. No patients experienced a significant adverse outcome. Conclusions: Avoiding the chest tube placement did not increase postoperative morbidity if carefully selected criteria are met.
Key Words: Chest tube placement • Video-assisted thoracic surgery • Wedge resection • Alternative sealing test
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1. Introduction
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A chest tube is usually inserted into the pleural cavity after wedge resection of the lung and left in place until there is no evidence of air leakage and fluid drainage is minimal. Devices and instruments used in video-assisted thoracoscopic surgery (VATS) have been improved greatly in recent years. Although air leaks from needle holes have sometimes been observed immediately after suturing with an atraumatic needle, air leaks from the staple line are uncommon except in patients with bullous and/or emphysematous changes of the lung or when the stapling instrument has been inappropriately used. We believe it is not always necessary to place a chest tube in a patient undergoing thoracoscopic wedge resection of the lung, and that unnecessary chest tube placement reduces the potential advantages of thoracoscopic wedge resection, such as diminished pain and shorter hospital stay. The aim of this study was to determine the validity and safety of postoperative management without chest tube placement for patients who have undergone thoracoscopic wedge resection of the lung.
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2. Patients and methods
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All patients scheduled to undergo elective thoracoscopic wedge resection of the lung during the period from January 1998 to December 2002 for pulmonary metastases (n=51), preoperatively indeterminate pulmonary nodules (n=29), interstitial diffuse pulmonary disease (n=12) or primary lung cancer (n=1) were enrolled in this study. Simultaneous bilateral wedge resections were performed in eight patients with bilateral metastatic lung tumors. In these eight patients, the side first approached was excluded from consideration because of the risk of an undrained pneumothorax while on positive pressure ventilation. A total of 93 consecutive patients were identified. During the period from January 1998 to December 1999, all 41 patients had a chest tube placed intraoperatively. Seven of these 41 patients had air leaks during the sealing test (5), dense pleural adhesion (3), and bullous and/or emphysematous changes (2). Three of these seven patients had two of these factors. The other 34 patients retrospectively meeting the criteria for avoiding chest tube placement received a chest tube (group 1). From January 2000 to December 2002, 42 patients meeting the given criteria did not receive a chest tube (group 2). Reasons for chest tube insertion included air leaks during the sealing test (7), dense pleural adhesion (2), bullous and/or emphysematous changes (2), and preoperative prolonged pleural effusion (1, pulmonary lymphangioleiomyomatosis with chyrothorax). Two patients with bullous disease also failed the sealing test. The following data were evaluated and analyzed between the two groups: patient characteristics, grade of pleural adhesion, number of resected specimens, number of stapler cartridges used, chest tube duration, postoperative morbidity, hospital stay, and postoperative pain. All patients who underwent thoracoscopic wedge resection from January 2000 to December 2002 gave written informed consent for avoiding chest tube placement before the operation and those that refused were excluded from the management.
2.1. Criteria for avoiding chest tube placement
The following criteria were used to determine if chest tube placement could be avoided: (1) absence of air leaks during an intraoperative sealing test, (2) absence of bullous or emphysematous changes in the lung, (3) absence of dense pleural adhesions, and (4) absence of prolonged preoperative pleural effusion requiring chest drainage. For patients undergoing simultaneous bilateral resections, only the second side operated on was considered for chest tube deferral.
2.2. Preoperative management
Indications for thoracoscopic wedge resection of the lung were the presence of lesions less than 3 cm in diameter within the outer third of the lung parenchyma as determined by examination of chest computed tomographic images [1]. Locations of tiny nodules less than 5 mm in diameter and nodules localized at depths of 3 cm or more from visceral pleura were determined by CT-guided localization using a short hook wire placement [2,3] (Hakko Medical Products, Tokyo, Japan) or transbronchial dye (methylene blue) injection [4].
2.3. Grade of pleural adhesion
In this study, we referred to the report on adhesion formation by Malm et al. [5] and pleural adhesions were classified by the density and severity as follows: severe, pleural adhesions were observed in the lung surface of two lobes or more intraoperatively, or it was difficult to dissect them bluntly; mild, pleural adhesions were observed in the lung surface of one lobe or less intraoperatively and it was easy to dissect them bluntly; and none, no pleural adhesions were observed intraoperatively.
2.4. Operative management
All resections were performed under general anesthesia with a thoracic epidural block and single lung ventilation with a double-lumen endotracheal tube. Intrathoracic access for exploration of the lung and pleura was usually obtained in the sixth or seventh intercostal space at the anterior mid-axillary line. Two additional access ports were required for grasping the lung, digital palpation of the lesions, and insertion of an endoscopic liner stapler (Endo-GIA, United States Surgical Corp, Norwalk, CT; ETS-45, Ethicon, Cincinnati, OH). The integrity of the parenchymal staple line and surrounding visceral pleura was assessed after reinflation of the lung. Large injuries of the lung caused by retraction, dissection of pleural adhesion or stapling failure were repaired.
2.5. Sealing test
Before December 1999, the lung was immersed in warm sterile saline, ventilated and observed. However, it was difficult to immerse the entire lung. In January 2000, we began to perform sealing tests by an alternative method to detect the presence or absence of air leaks (though localization of air leaks is not possible using this method). In the alternative method, a silicon chest tube was inserted into the pleural cavity. The wounds of the chest wall were temporarily closed. The chest tube was then placed underwater to seal and the patient was ventilated at 15 cmH2O of maximum inspiratory pressure and examined for air leaks. If air leaks were found, a conventional intrapleural sealing test was carried out. If air leaks were identified, they were closed using sutures, staples or fibrin glue. If minor air leaks were observed during the alternative sealing test, a chest tube was placed prior to closure. A chest tube was not inserted if no air leakage was observed.
2.6. Postoperative management
A chest roentgenogram was taken in all patients in the operating room 10–15 min after completion of the operation before the patient woke from anesthesia. We performed thoracentesis when air space accounted for over one fourth of pleural space even if a patient is asymptomatic and chest tube was placed if air leaks were observed after deairing. No further roentgenograms were taken until the date of discharge unless chest abnormalities, particularly in auscultation, were noted. Chest tubes were left until air leaks had stopped and removed 1 day after cessation of any leaks and until the amount of drainage is less than about 200 cm3/day (30 cm3/kg per day). They were discharged from the hospital when they were capable of independent care.
2.7. Postoperative analgesia
All patients received continuous epidural bupivacaine with or without fentanyl until postoperative day (POD) 2. Thereafter, rokisoprophen sodium (Rokisonin, Sankyo Co. Ltd., Tokyo, Japan) was given daily at an oral dose of 180 mg for 7 days.
2.8. Evaluation of postoperative pain
Postoperative pain was assessed at rest after the patient awoke in the morning from POD 1 to POD 7 using the visual analogue scale described by Hazelrigg et al. [6]. This involved patients drawing a pain score from 0 cm (absent) to 10 cm (most severe imaginable) on a 10-cm line chart. To ensure that there were no obvious psychological differences in the groups with regard to pain perception, a pain reference was determined preoperatively in each patient as described previously [7].
2.9. Statistical analysis
All continuous variables are expressed as means±SD. Differences between the two groups were assessed by means of Students' t-test after the assurance of homogeneity by Levene's test. Categorical data were compared using the Fisher's exact test. All reported probability values are two-tailed, and P-values of less than 0.05 were considered statistically significant. Statistical analyses were performed using SPSS 10.0 software (SPSS, Inc., Chicago, IL).
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3. Results
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3.1. Clinical data and morbidity
Clinical data are summarized in Table 1. There were no differentiations between the two groups except the duration of chest tube placement. The postoperative courses of patients in groups 1 and 2 are shown in Table 2. In two patients in group 2 occurred a pneumothorax requiring chest drainage after the operation. One was a 70-year-old male patient with two pulmonary metastases from renal cell carcinoma. The operating room radiograph showed a pneumothorax and thoracentesis and air evacuation was performed. It was thought that intraoperative air evacuation had been insufficient. The other was a 65-year-old female patient with a solitary breast metastasis. The operating room chest radiograph showed a small pneumothorax, but the pneumothorax was thought to be caused by insufficient air evacuation and required no chest tube insertion in the operating room. In the recovery room, she complained of dyspnea and her right chest sounds became faint. A chest radiograph showed a large right pneumothorax. An 8-Fr chest drainage catheter was inserted. An atelectatic lung around the site of air leakage is thought to be the reason why the sealing test did not reveal air leaks intraoperatively. The operating room chest radiograph showed a low-grade pneumothorax in two other patients, but they were managed with clinical and radiographic observation. There were no deaths during the period of hospitalization or within 30 days after surgery.
3.2. Postoperative chest pain
Postoperative drug requirement was similar in the two groups, taking into consideration that the analgesic regimen was standardized. There were no differences in the mean value of the visual analogue scale on POD 1, POD 2, POD 3 and POD 7 between the two groups (Table 3).
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4. Discussion
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A chest tube is frequently placed in the pleural cavity after wedge resection by open thoracotomy to monitor and treat any air leaks and to remove any blood or pleural fluid that collects. Several methods for management of chest tubes have been reported [8–10]. Some surgeons believe that leaving the chest tube in place for 1 or 2 days after lung resection provides a safety net and will reduce the incidence of early postoperative complications such as pneumothorax or retained hemothorax. Although wedge resection by VATS has some advantages such as less pain, smaller incisions and less trauma, many general thoracic surgeons have managed chest tubes after wedge resection by VATS the same as after that by open thoracotomy. Because of remarkable improvements in recent years in instruments and devices used in VATS, there should be very few air leaks and little bleeding from the stapler line if instruments are used correctly. In these situations, we established the criteria for avoiding chest tube placement. Patients at risk for significant air leak or pleural effusion were excluded from the criteria. Thus, patients with bullas or emphysema were excluded because of an increased risk of postoperative development of new air leaks from the staple line. Patients with dense pleural adhesion were excluded because of the substantial risk of unrecognized injuries from sites remote to the staple line. Patients with preoperative prolonged pleural effusion were excluded because of the high necessity of postoperative chest tube drainage. Finally, the first side operated on for patients undergoing synchronous bilateral procedures was excluded because of the high risk of developing an air leak from a new staple line subjected to positive pressure ventilation and the potentially catastrophic development of a tension pneumothorax. Only 2 of 42 patients managed with this policy required new intervention. These patients were treated early on in the study period and it is thought that removal of sputum to prevent atelectasis, videoscopic confirmation of full expansion of the lung, and deairing were insufficient. In both instances, no major problems were encountered. The result shows that avoiding chest tube placement does not hinder the safety of thoracoscopic wedge resection of the lung. The presence or absence of chest tube placement did not impact postoperative chest pain in this study, it is likely the use of epidural block may have blurred the effect of avoiding chest tube placement on pain after thoracoscopic wedge resection, or pain due to not placing a chest tube but incision wounds on the chest wall may have prescribed the grade of postoperative pain. Although the effect of avoiding chest tube placement on postoperative pain was not revealed, it is clear that avoiding chest tube placement relaxes the restrictions on patients turning over in their sleep and/or lying postoperatively on their side. They do not feel the chest tube, which is usually a nuisance, and removing the chest tube is unnecessary. Furthermore, we can save the cost of the chest drainage kit to which a chest tube is connected. Another advantage of avoiding chest tube placement is that it forces the operator to conduct a more careful search for air leakage and repair it, if necessary.
4.1. Study limitations
This study has several limitations. Although clinical follow-up was complete, the study was a retrospective case series study with all its recognized limitations. Pulmonary function was measured only preoperatively and the function during the early postoperative period was not estimated. Furthermore, although the shortening of hospital stay might have been one of the advantages of avoiding chest tube placement, we think that the duration of hospital stay did not reflect postoperative condition of these patients because the Japanese healthcare system is unique in that patients are permitted to stay at the hospital, not only for postoperative care, but also for rehabilitation until they are confident that they can conduct daily activities independently.
4.2. Conclusion
No severe postoperative complications occurred in patients in whom a chest tube was not placed after thoracoscopic wedge resection of the lung. No advantage as to postoperative pain was observed in patients who did not have a chest tube placed after thoracoscopic wedge resection of the lung. Avoiding chest tube placement does not hinder the safety of thoracoscopic wedge resection of the lung if certain criteria are met.
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Footnotes
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Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.
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References
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Top
Abstract
1. Introduction
