Regulated drainage reduces the incidence of recurrence after uniportal video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax: a propensity case-matched comparison of regulated and unregulated drainage†.

OBJECTIVES: To compare the recurrence rate of primary spontaneous pneumothorax (PSP) after uniportal video assisted thoracic surgery (VATS) bullectomy and mechanical pleurodesis in patients managed with a regulating pressure drainage system compared and those managed with a traditional one. METHODS: Retrospective propensity score case-matched analysis of 174 consecutive patients submitted to uniportal VATS bullectomy and mechanical pleural abrasion (2007-13) in two centres. Definition of recurrence: Recurrent PSP requiring new treatment (i.e. aspiration, chest tube reinsertion, reoperation) within 12 months from the operation. All patients were managed with a single 24-Fr chest tube. Group 1 (106 patients): Tube connected to a traditional device (T) maintained on wall suction (-20 cmH2O) for 48 h. Group 2 (68 patients): Tube connected to a regulating pressure device (R) set at -20 cmH2O for 48 h. Chest tube removal criteria: No air leak (no bubbling or air flow <20 ml/min for at least 8 h) and pleural effusion <200 ml/day. Propensity score case-matching analysis was performed using the following variables: Age, gender, height, weight, side of operation, dystrophic score, length of stapled parenchyma. RESULTS: The two groups of 68 pairs were well matched for baseline and surgical characteristics. Patients of Group 2 (R) showed a significantly lower incidence of recurrence rate compared with matched counterparts (T) (3, 4.4 vs 10, 14%, P = 0.041). There were no differences in persistent air leak incidence, chest tube duration or hospital stay between the groups. Group 2 had a higher 48-h output of pleural effusion compared with Group 1 (P < 0.0001). CONCLUSIONS: By stabilizing the pleural pressure at the preset values, novel regulating pressure devices may enhance pleurodesis, leading to a reduced incidence of PSP recurrences after uniportal VATS bullectomy and pleural abrasion.

An aggregate score to predict the risk of large pleural effusion after pulmonary lobectomy.

OBJECTIVES: The volume of pleural effusion is one of the determinants of chest drain removal following pulmonary resection. Recent research suggests that values up to 400 ml/day are safe. The objective of this study was to develop an aggregate risk score to identify patients at higher risk of developing a large pleural effusion (LPE) (>400 ml/day) on postoperative day 2 (POD2) after pulmonary lobectomy. METHODS: An observational study on 229 consecutive patients was conducted prospectively in two European centres (June 2012-September 2013). All patients underwent pulmonary lobectomy for lung cancer (thoracotomy: 131, video-assisted thoracic surgery: 98) and managed by single chest tube connected to an electronic-regulated suction device. Exclusion criteria were chest wall or diaphragm resection and postoperative-assisted mechanical ventilation. To build the aggregate score, variables were initially screened by univariable analysis, and then used in stepwise logistic regression analysis (validated by bootstrap). The scoring system was developed by proportional weighing of the significant predictor estimates, and patients were grouped in classes of incremental risk according to their total score. RESULTS: The incidence of LPE on POD2 was 23% (53 of 229 patients). The independent risk factors associated with LPE on POD2 were age greater than 70 years (P = 0.01, bootstrap frequency 71%), a lower lobectomy (P = 0.03, bootstrap frequency 59%) and presence of COPD (P = 0.02, bootstrap frequency 63%). Each predictor received a weighted score of 1, and patients were grouped into three risk classes showing an incremental risk of LPE (P < 0.001): Class A (Score 0) 5 LPE in 66 patients, 7.5%; Class B (Score 1) 19 LPE in 88 patients, 22%; Class C (Score >1) 29 LPE in 75 patients, 39%. CONCLUSIONS: The aggregate score is a reliable tool for identifying high-risk patients for LPE and assists in the selection of patients that can safely proceed to chest drain removal early after surgery.