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Letters to the Editor |
Cardio-Thoracic Surgery Department, University Hospital, Medical School of Patras, Patras, Greece
Received 15 April 2009; accepted 24 April 2009.
* Corresponding author. Address: Kolokotroni 4, Ovria, 26500 Patras, Greece. (Email: ngbaik{at}yahoo.com).
Key Words: Chest drainage • Double tubes for chest drainage • Indications for chest drainage • Lung excision • Single chest tube for chest drainage
Your interesting study [1] on the ideal way of pleural drainage after lung resection, which, despite its importance, is hardly reported upon in the literature: no more than 30 papers during the last 30 years. However, most cardiothoracic centres apply a single tube in the majority of lung resections. The advantage of a single chest tube is not only because it minimizes the pain, given that the pain is completely due to the thoracotomy [2], but also because it provides easy mobility and facilitates respiratory physiotherapy for the patient. In addition, it secretes less fluids into the pleural cavity. Every synthetic material (e.g. drainage tube), introduced into the pleural space stimulates the production of sterile fluid, which is added to that produced by the surgical manipulation of the lung and pleura. However, in your study (see Table 1), other preoperative factors – which are certainly related to the blood and liquid overproduction during the early postoperative period – have not been included. These factors are, no doubt, pathological preoperative clotting mechanisms – the anti-platelet medication, the presence of atrial fibrillation, congestive heart failure, etc. These patients should be excluded from the meta-analysis, unless the similarity of the two groups is demonstrated in the table presented in your paper. In our opinion, the decision with regards to the placement of a single or two chest tubes should have been made intra-operatively, based on the following two criteria: if early postoperatively air and/or liquid leak is expected. If you expect one or both of the conditions mentioned above, the placement of two chest tubes (at the apical and basal positions) are proposed, with the removal of the tube in the basal position carried out at the earliest possible time following the management prescribed according to several protocols [3,4]. Independent of the quantity of drainage, which may be 
450 [3] or 150–200 ml/24 h [5], a presupposition needs to be considered for chest-tube removal: the resting lobe should not be atelectatic. If this condition is acceptable, the chest-tube removal without a bronchoscopy for the lysis of the atelectasis will probably result in a recurrent pleural effusion.
Giving credence to this issue, we evaluated candidates for a double-chest-tube placement from among the following patients: (a) patients with incomplete interlobar fissures that require the use of automatic suture devices for their preparation, (b) patients who had undergone preoperative radiotherapy, (c) patients with diffuse adhesions, (d) patients for whom the resting lobe (tested passively by the anaesthetist) seems to incompletely occupy the entire hemithorax (e.g., upper lobectomy, bilobectomy) and finally a significant dead space is created, (e) patients with chest-wall infiltration (T3), which requires chest-wall resection, (f) patients with preoperatively diagnosed coagulopathy, intake of anti-platelet or coumarinic medication and (g) patients with hepatic, renal or symptomatic congestive heart failure with or without precedent pleural effusion.
In the remaining patients, we could place only one apical chest tube with two key features: first, the tube was introduced through the lowest intercostal level (at the level of the diaphragm) and, second, tube insertion was performed after making some additional holes for every 2–3 cm along the tube.
References
This article has been cited by other articles:
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  E. Okur, V. Baysungur, C. Tezel, and S. Halezeroglu Reply to Apostolakis and Baikoussis: There is no need to drain the excessive pleural fluid accumulation after pulmonary lobectomies Eur. J. Cardiothorac. Surg., August 1, 2009; 36(2): 425 - 425. [Full Text] [PDF]
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