ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery 45 (2014) 241–246 doi:10.1093/ejcts/ezt376 Advance Access publication 19 July 2013
Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day† Lars S. Bjerregaarda,*, Katrine Jensenb, Rene Horsleben Petersenb and Henrik Jessen Hansenb a b
Department of Cardiothoracic Anaesthesia and Section for Surgical pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
* Corresponding author. Department of Cardiothoracic Anaesthesia and Section for Surgical pathophysiology, Rigshospitalet, section 7621, Blegdamsvej 9, DK-2100 Copenhagen. Tel: +45-3545-8946; fax: +45-3545-2784; e-mail:
[email protected] (L.S. Bjerregaard).
Abstract OBJECTIVES: In fast-track pulmonary resections, we removed chest tubes after video-assisted thoracic surgery (VATS) lobectomy with serous fluid production up to 500 ml/day. Subsequently, we evaluated the frequency of recurrent pleural effusions requiring reintervention. METHODS: Data from 622 consecutive patients undergoing VATS lobectomy from January 2009 to December 2011 were registered prospectively in an institutional database. Data included age, gender, lobe(s) resected, bleeding and duration of surgery. Follow-up was 30 days from discharge. All complications requiring pleurocentesis or reinsertion of a chest tube, and all readmissions were registered. Twenty-three patients were excluded due to missing data, in-hospital mortality and loss to follow-up, leaving 599 for final analysis. Our primary outcome was the number of patients requiring reintervention due to recurrent pleural effusion. Secondary outcomes included time of chest tube removal and time to discharge. The incidence of recurrent pleural effusions requiring reintervention was compared between three groups according to the postoperative day (POD) of chest tube removal (Day 0–1, 2–3 and ≥4, respectively) using Fisher’s exact test. RESULTS: Pleural effusion after chest tube removal required reintervention in 17 patients (2.8%). Of these, 7 needed readmission. Median time from surgery to chest tube removal was 2 days, and median time from surgery to discharge was 4 days. No statistically significant association was found between the incidence of reinterventions due to recurrent pleural effusion and the POD of chest tube removal (P = 0.50). The median time from chest tube removal to discharge was 1 day in all groups. Of the patients who needed reintervention, none had complications regarding this, except one who developed pneumothorax after pleurocentesis. CONCLUSIONS: Our findings suggest that chest tube removal after VATS lobectomy is safe despite volumes of serous fluid production up to 500 ml/day. The proportion of patients who developed pleural effusion necessitating reintervention was low (2.8%), and a complication of the reintervention was seen in only 1 patient. Keywords: Video-assisted thoracic surgery • Lobectomy • Chest tube • Fast-track surgery • Pleural effusion
INTRODUCTION In fast-track surgery, the idea is to enhance postoperative recovery by optimizing all factors involved in the treatment of surgical patients. The concept was first described in relation to colorectal surgery in the 1990s, and is still an area of on-going improvement [1]. During the last two decades, the fast-track surgery approach has been applied to different specialties including thoracic surgery [2–4]. An important step in fast-tracking pulmonary resections is the early removal of chest tubes, which cause pain, impair mobilization and impose a risk of infection. A consensus on when to remove the chest tube after pulmonary resections on the basis of the amount of pleural drainage has
not yet been reached [5], and recently proposed standardized definitions and nomenclature on chest tube related topics, require studies of more standardized patients with clinically relevant outcomes [6]. In fast-track pulmonary resections, we have removed chest tubes after video-assisted thoracic surgery (VATS) lobectomy despite volumes of serous pleural drainage up to 500 ml/day. In this study, we evaluated the frequency of recurrent pleural effusions requiring reintervention as a result of this strategy. Although we recognize the relevancy of air leak in relation to early chest tube removal, this was not the objective of the present study and therefore the discussion focusses on early chest tube removal, recurrent pleural effusion and the consequences of this complication.
† Presented at the 21st European Conference on General Thoracic Surgery, Birmingham, UK, 26–29 May 2013.
© The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
THORACIC
Received 13 February 2013; received in revised form 26 March 2013; accepted 31 May 2013
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MATERIALS AND METHODS Patient inclusion and approval According to Danish law, this was considered a quality insurance process by The Regional Ethics Committee, due to its observational, non-interventional design. The study was approved by the Danish Data Protection Agency (Capital region, Denmark). Data were registered on 622 consecutive patients undergoing elective VATS lobectomy between January 2009 and December 2011. Nine patients were excluded due to missing data and in-hospital mortality, and 14 patients were lost to follow-up (Fig. 1).
Patients characteristics, operative data and follow-up Data on age, gender, type of resection (uni- or bilobectomy, ± wedge resection), intraoperative bleeding (volume in floor suction), duration of surgery, postoperative day (POD) of chest tube removal, POD of discharge and complications during the admission were collected prospectively in an institutional database. Follow-up was 30 days from discharge, where records on all discharged patients were retrieved from E-journal (A Danish national system recording all admissions and reasons for admission). All complications requiring pleurocentesis or reinsertion of a chest
Figure 1: Flow chart of study profile.
tube were registered, as were all readmissions and their causes. If a patient were transferred to another hospital, the day of transmission were registered as POD of discharge, but follow-up was 30 days from final discharge.
Outcomes Our primary outcome was the number of patients developing recurrent pleural effusion requiring pleurocentesis or reinsertion of a chest tube. Secondary outcomes were POD of chest tube removal and its association with the incidence of recurrent pleural effusions, POD of discharge, time from chest tube removal to discharge and the cumulative time of readmission due to recurrent pleural effusion.
Surgery All operations were performed by one of two highly experienced surgeons (H.J.H. and R.H.P.) via a standardized anterior approach, with three ports identically placed independently of the lobe to be resected. The patient was placed in the lateral position, and the intercostal spaces were opened by arching the operating table. The procedure was performed in a bimanual fashion, the surgeon using two instruments through two of the insertions, while the camera
L.S. Bjerregaard et al. / European Journal of Cardio-Thoracic Surgery
Chest tube management A size 28 French, Portex chest tube (Smiths Medical, Ashford, UK) was placed at the end of operation. A few patients had two tubes placed if significant postoperative air leak was suspected, or in the case of bilobectomy. Chest tubes were removed when output (not blood, not chylos) was
