When to Remove a Chest Tube

There is no consensus on postoperative thoracostomy tube management in thoracic patients, specifically whether or not a chest radiograph is required after tube removal.

Retrospective review of video-assisted thoracoscopic (VATS) lobectomy patients was performed at a large tertiary referral center from January 1, 2019 to December 31, 2020. Patients were grouped as asymptomatic or symptomatic after thoracostomy removal. Demographic data and clinical outcomes were evaluated. Descriptive statistics, Fisher's exact and Wilcoxon rank sum tests were performed.

202 of 208 patients were asymptomatic after thoracostomy removal. Demographic data between those who were asymptomatic and symptomatic revealed no differences except for a higher FEV1/FVC in the asymptomatic group. Median length of stay for asymptomatic and symptomatic patients was 2.0 and 3.5 (p=0.295). 62% of asymptomatic versus 100% of symptomatic patients had abnormal post-pull radiographs (p=0.088). No one in the asymptomatic group required an intervention after thoracostomy removal and prior to discharge whereas 66.7% in the symptomatic group required a procedure (p<0.0001).

Our study revealed that rather than abnormal radiography, presence of symptoms correlated with the need for further intervention. Notably, many of our patients had abnormal post-pull radiographs but did not develop symptoms and were successfully discharged without complication. Only patients with symptoms required an intervention after thoracostomy removal.

Patient symptoms, not radiographic findings, determine the need for intervention after thoracostomy removal in VATS lobectomy patients. Post-pull chest radiographs may not need to be obtained if the patients have no clinical symptoms and signs.

La cirugía del cáncer de esófago es un procedimiento complejo con tasas de morbimortalidad elevadas, por lo que para obtener resultados adecuados se precisa de centros experimentados, un completo soporte multidisciplinar y vías clínicas adecuadas. Se describe la experiencia inicial y la técnica de la esofaguectomía «tubeless» en la que tras realizar una resección esofágica y linfadenectomía mediastínica extendida, al final del procedimiento no son colocados drenajes ni sondas de ningún tipo, con el fin de disminuir la agresividad del mismo, mejorar el bienestar postoperatorio y acelerar la recuperación funcional del paciente.

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of “tubeless” esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery.

A 58-year-old man on direct oral anticoagulant therapy for paroxysmal atrial fibrillation was involved in a motorcycle accident, resulting in thoracic and head trauma. He had severe acute respiratory failure and underwent endotracheal intubation and invasive mechanical ventilation in the intensive care unit.

Total-body computed tomography (CT) showed multiple fractures (several ribs bilaterally, T2 vertebra, and bilateral sacral ala). On the right side, pleural effusion, pulmonary contusion, and thin pneumothorax were found. Prothrombin complex concentrate was administrated to obtain rapid replacement of coagulation factors, followed by placement of a right pleural drain, resulting in dark blood coming out. About 24 hours later, sudden worsening of oxygen parameters occurred as a result of large right pneumothorax. The pleural drain was blocked by clots and was urgently replaced with a larger-bore tube. There was abundant air leakage, which persisted for several days. A digital drainage system helped assess the progressive air leak reduction. The patient improved clinically and was extubated. When bubbling stopped, the second chest tube was removed, and an invasive procedure was no longer needed.

This chapter deals with hemothorax and bloody pleural effusions, analog and digital pleural drainage systems, and strategies for the reversal of the effects of anticoagulant drugs.

Chest wall resection for sarcoma can present a surgical challenge. The unique concerns of the chest wall, including a confluence of anatomic and physiologic systems, may require a multispecialty surgical team to address the necessities of achieving a wide sarcoma resection. We present our experience with chest wall resection and reconstruction for sarcoma, including the surgical technique and a case series.

New digital thoracic drainage systems allow an objective measurement of air leakage. They have proven their usefulness in the postoperative thoracic surgery in adults, but there is little experience with its use in the pediatric population. The objective of our study is to analyze their safety and effectiveness in the postoperative period of the pediatric patients.

A prospective consecutive observational study was done. All patients submitted to pulmonary resection between 2011 and 2017 and in whom digital thoracic drainage system was used (Thopaz Chest Drain System, Medela, Switzerland) were prospectively enrolled in this study. We analyzed variables: duration of chest tube (CT), days of hospitalization and radiographs in the immediate postoperative period related to the presence of CT. This group was compared with a historical cohort of patients (from 2011 to 2015) with a pulmonary resection in whom the traditional thoracic drainage was used. For the statistical analysis, the Mann–Whitney U-Test was used for independent samples.

Twenty-six patients were included, Digital drainage system was used in13 patients and traditional drainage was used in 13 patients. The median age was 18 months (12 days-14 years). The mean number of days with the chest tube was 1.69 ± 0.6 in digital drainage group versus 5.38 ± 4 days in traditional drainage group (p < 0.05) The mean number of postoperative radiographs was 2.8 ± 1.1 in digital drainage group versus 6.23 ± 5.2 radiographs in traditional drainage group (p < 0.05). The average hospital stay in digital drainage group was 5.69 ± 2.7 days versus 7 ± 4.7 days in the traditional drainage group (p > 0.05). No complications related to the use of digital drainage group were registered.

The digital thoracic drainage systems provide an objective measurement of air leakage, allowing early chest tube removal and decreasing the number of radiographs performed postoperatively. Its use in the pediatric population appears to be safe and potentially beneficial.

II.

Indication for postdrain removal imaging after lung resection is debated. Chest roentgenogram (CR) is widely used to confirm lung expansion but not evidence based. We propose to introduce lung ultrasound (LUS) as alternative to exclude significant pneumothorax (PTx) in this setting.

The study enrolled 50 patients undergoing lung resections. Inclusion criteria were complete expansion of the lung at postoperative CR, pleural effusion of less than 300 mL/24 h, air leak of 10 to 20 mL/min for 6 hours. Two hours after chest drain removal, LUS was performed at the second and third intercostal spaces to assess pleural sliding. Patients with no detected PTx or with apical PTx were considered for discharge. The same patients were blindly evaluated with CR by a second operator, and a comparison between the two methods was performed. Clinical decisions were taken based on CR results.

LUS confirmed large PTxs in 7 patients, apical PTxs in 10 patients, and no PTx in 33 patients. CR confirmed 5 of 7 significant PTxs (1 chest drain reinserted, 4 patients observed), and 2 of 7 PTx were considered irrelevant. Apical PTxs were confirmed in 8 of 10 patients, and in 2 patients there was no PTx at CR. The 33 patients with no PTx at LUS had full lung expansion at CR. LUS has a negative predictive value of 100% in excluding large PTxs and a positive predictive value of 71%.

In this subgroup of patients with air leak of 10 to 20 mL/min, performing an imaging study to verify the absence of PTx is desirable; however, when LUS confirms lung expansion or the presence of apical PTx, CR does not seem to be needed.