Bronchial Valves for Persistent Air Leak: A Systematic Review and Meta-analysis.

BACKGROUND: Patients with persistent air leak (PAL) pose a therapeutic challenge to physicians, with prolonged hospital stays and high morbidity. There is little evidence on the efficacy and safety of bronchial valves (BV) for PAL. METHODS: We systematically searched the PubMed and Embase databases to identify studies evaluating the efficacy and safety of BV for PAL. We calculated the success rate (complete resolution of air leak or removal of intercostal chest drain after bronchial valve placement and requiring no further procedures) of BV for PAL in individual studies. We pooled the data using a random-effects model and examined the factors influencing the success rate using multivariable meta-regression. RESULTS: We analyzed 28 observational studies (2472 participants). The pooled success rate of bronchial valves in PAL was 82% (95% confidence intervals, 75 to 88; 95% prediction intervals, 64 to 92). We found a higher success rate in studies using intrabronchial valves versus endobronchial valves (84% vs. 72%) and in studies with more than 50 subjects (93% vs. 77%). However, none of the factors influenced the success rate of multivariable meta-regression. The overall complication rate was 9.1% (48/527). Granulation tissue was the most common complication reported followed by valve migration or expectoration and hypoxemia. CONCLUSION: Bronchial valves are an effective and safe option for treating PAL. However, the analysis is limited by the availability of only observational data.

Effectiveness of Stitch With Pledget to Prevent Prolonged Air Leak in Thoracoscopic Lung Resection.

INTRODUCTION: We previously demonstrated the usefulness of combining stitching with covering to seal alveolar air leaks in an animal model. This study aimed to clarify the effectiveness and feasibility of this sealing method in the clinical setting. METHODS: Data of 493 patients who underwent thoracoscopic anatomical resection between 2013 and 2020 for lung cancer were retrospectively reviewed. Prolonged air leak was defined as chest drain placement lasting 5 d or longer due to air leak. Until July 2017 (early study period), we covered air leaks using mesh. However, for sealing (late study period), we additionally stitched leaks with pledget in patients at high risk of prolonged air leak. The pneumostasis procedure, intraoperative confirmation test of pneumostasis, and chest tube management were uniform during both periods. RESULTS: The incidence of prolonged air leak was significantly lower in the late than in the early period (3.6% versus 12.5%), whereas pulmonary emphysema was more severe in the late period compared to the early period. Intraoperative failure of sealing air leaks was significantly reduced in the late period than in the early period. In both univariate and propensity score matching analysis, the study period was a significant predictor of prolonged air leak. CONCLUSIONS: The combination of stitching and covering with mesh may contribute to reducing prolonged air leak incidence in patients undergoing thoracoscopic anatomical lung resection for lung cancer.

Autologous blood patch intraparenchymal injection reduces the incidence of pneumothorax and the need for chest tube placement following CT-guided lung biopsy: a systematic review and meta-analysis.

PURPOSE: To assess the effectiveness of autologous blood patch intraparenchymal injection during CT-guided lung biopsies with a focus on the incidence of pneumothorax and the subsequent requirement for chest tube placement. METHODS: A comprehensive search of major databases was conducted to identify studies that utilized autologous blood patches to mitigate the risk of pneumothorax following lung biopsies. Efficacy was next assessed through a meta-analysis using a random-effects model. RESULTS: Of the 122 carefully analyzed studies, nine, representing a patient population of 4116, were incorporated into the final analysis. Conclusion deduced showed a noteworthy reduction in the overall incidence of pneumothorax (RR = 0.65; 95% CI 0.53-0.80; P = 0.00) and a significantly decline in the occasion for chest tube placement due to pneumothorax (RR = 0.45; 95% CI 0.32-0.64; P = 0.00). CONCLUSIONS: Utilizing autologous blood patch intraparenchymal injection during the coaxial needle retraction process post-lung biopsy is highly effective in diminishing both the incidence of pneumothorax and consequent chest tube placement requirement.

Chest drains after open paediatric lung resections: not always required.

INTRODUCTION: Chest drains are often a great source of pain and anxiety in paediatric patients. While there is growing evidence to support the selective omission of chest drains after thorascopic lung resection in children, the safety of this practice following open lung resection has yet to be evaluated. Chest drains are not routinely placed at our institution. We therefore aimed to describe our experience of selective chest drain placement in children undergoing open lung resection, and report the safety and complication profile of this practice. METHODS: Retrospective review of all open lung resections performed at Wellington Regional Hospital, in children < 16 years of age, from June 2009 to June 2022. Clinical, radiological and operative outcomes were identified and analyzed. The cohort was divided into two groups - those that had a chest drain placed intraoperatively, and those that did not. RESULTS: 35 children underwent open lung resection over the study period. The mean operative age was 8.0 ± 5.4 months, with the most common resection being a lobectomy (80%). Eight children (23%) did not have a chest drain placed, whereas the remaining 29 children (77%) had at least one drain placed intraoperatively, with a median drainage time of 3.0 days. Length of stay was significantly shorter in children who did not have a chest drain placed intraoperatively, compared to those that did (2.5 vs. 5.0 days, p = 0.019). There were no significant differences observed in complication or reintervention rates between the two groups. Similarly, there were no significant differences in the incidence of a residual pneumothorax or effusion on the pre-discharge CXR between the groups. CONCLUSIONS: Chest drains may not always be required following open paediatric lung resection. The selective omission of a chest drain following open lung resection, does not appear to result in a significantly higher rate of complications or reintervention, and is associated with significantly shorter hospital length of stay.

Interfacility Transport of Children with Traumatic Pneumothorax: Does Elevation Make a Difference?

INTRODUCTION: Traumatic pneumothorax (PTX) remains a source of significant morbidity and mortality in pediatric trauma patients. Management with tube thoracostomy is routinely dictated by symptoms, use of positive pressure ventilation, or plan for air transport. Many patients transferred to our pediatric trauma center (PTC) require transport at considerable elevation. We sought to characterize the effect of transport at elevation in this population to inform management recommendations. METHODS: The trauma registry was queried for pediatric patients transferred to our tertiary referral center with traumatic PTX from 2010 to 2022, yielding 412 charts for analysis. Data abstracted included mechanism of injury, mode of transport, size of pneumothorax, chest tube placement, endotracheal intubation, and estimated elevation change during transport. RESULTS: There were 412 patients included for analysis. Most patients had small pneumothoraces that resolved without chest tube placement (388 patients, 94.1%). No patients experienced acute respiratory decompensation in transport. There were four (0.9%) patients with increased PTX on arrival, however, none experienced acute decompensation as a result. Average elevation gain was 2337 feet. There was no association between elevation change and requirement of post-transport chest tube placement. No patients experienced PTX-related complications after discharge. CONCLUSIONS: In this large patient series, no patient experienced a meaningful increase in the size of their traumatic PTX during or immediately following transport at elevation to our institution. These findings suggest it is safe to transfer a pediatric trauma patient with a small, hemodynamically insignificant PTX without tube thoracostomy despite considerable changes in elevation during transport. LEVELS OF EVIDENCE: II-III, Retrospective Study.

Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection.

OBJECTIVES: The need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients. METHODS: Patients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses. RESULTS: A total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion. CONCLUSIONS: Reserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.

Safety of Home Discharge With a Chest Tube After Bronchoscopic Lung Volume Reduction Complicated by Persistent Airleak.

BACKGROUND: The incidence of pneumothorax after bronchoscopic lung volume reduction (BLVR) using Zephyr (Pulmonx Corporation) endobronchial valves is ~26%. Many patients who develop a postprocedural pneumothorax require chest tube placement. If a persistent airleak is present, patients tolerating waterseal can be discharged home with a mini-atrium with a low risk of empyema. METHODS: Data were collected on patients from the Epic (Epic System Corporation) electronic medical record between July 2019 and November 2022. Our retrospective study reviewed a total of 102 BLVR procedures. Twenty-six of these procedures were complicated by a pneumothorax post-BLVR (25%). After 24 procedures, patients were discharged home with a chest tube after a persistent airleak. The primary endpoint of the study was the incidence of intrapleural infection in this population. The secondary endpoint was the average length of time the chest tube was in place until outpatient removal. RESULTS: Out of the 24 discharge events, 2 events (8.3%) were complicated by an intrapleural infection before chest tube removal. The average number of days requiring a chest tube until outpatient removal was 16.9 days, which is similar to the duration observed in patients discharged home with a chest tube after lung volume reduction surgery. CONCLUSION: Discharging patients home with a chest tube after BLVR therapy is safe and may reduce hospital length of stay. Our study shows the incidence of intrapleural infection after home discharge with a chest tube after BLVR is low.

Perioperative outcomes of bi-pigtail catheter drainage strategy versus conventional chest tube after uniportal video-assisted thoracic lung surgery.

OBJECTIVES: Chest tube (CT) drainage is a main cause of postoperative pain in lung surgery. Here, we introduced a novel drainage strategy with bi-pigtail catheters (PCs) and conducted a randomized controlled trial to compare with conventional CT drainage after uniportal video-assisted thoracic surgery lung surgery. METHODS: A single-centre, prospective, open-labelled, randomized controlled trial (ChiCTR2000035337) was conducted with a preplanned sample size of 396. The primary outcome was the numerical pain rating scale (NPRS) on the first postoperative day. Secondary outcomes included other indicators of postoperative pain, drainage volume, duration of drainage, postoperative hospital stay, incidence of postoperative complications, CT reinsertion and medical costs. RESULTS: A total number of 396 patients were randomized between August 2020 and January 2021, 387 of whom were included in the final analysis. The baseline and clinical characteristics of the patients were well balanced between 2 groups. The NPRS on the first postoperative day was significantly lower in the PC group than in the CT group (2.40 ± 1.27 vs 3.02 ± 1.39, p < 0.001), as well as the second/third-day NPRS, the incidence of sudden severe pain (9/192, 4.7% vs 34/195, 17.4%, P < 0.001) and pain requiring intervention (19/192, 9.9% vs 46/195, 23.6%, P < 0.001). In addition, the medical cost in the PC group was lower (US$7809 ± 1646 vs US$8205 ± 1815, P = 0.025). Univariable and multivariable analyses revealed that the drainage strategy was the only factor influencing the incidence of pain requiring intervention. CONCLUSIONS: The drainage strategy with bi-PCs in patients undergoing uniportal video-assisted thoracic surgery lung surgery alleviates postoperative pain with adequate safety and efficacy.

Algoritmo diagnóstico y terapéutico de las lesiones esplácnicas provocadas durante la inserción de sondas pleurales / Diagnostic and Therapeutic Algorithm for Splanchnic Injuries Caused during Chest Tube Insertions

Introducción: La colocación de sondas pleurales es un procedimiento quirúrgico frecuente que puede tener graves complicaciones, las cuales dependen en la mayoría de los casos de la experiencia del operador, el tamaño del tubo y el uso de imágenes para guiar la inserción. Objetivo: Describir las principales lesiones esplácnicas provocadas durante la inserción de sondas pleurales y presentar algoritmos para el diagnóstico precoz y el tratamiento oportuno de estas iatrogenias. Métodos: Se realizó una revisión descriptiva narrativa durante el primer trimestre del año 2023. Se utilizaron las bases de datos electrónicas PubMed, LILACS, EBSCO y Cochrane. Se revisaron artículos publicados desde 1984 hasta el 2022. Se procuró que la mayoría de la información se enmarcara en un período no mayor de 10 años de antigüedad. Desarrollo: De las lesiones esplácnicas de la cavidad torácica, la de pulmón es la más frecuente y puede conducir a sangrado o fuga aérea persistente. Las lesiones vasculares son graves y pueden provocar la muerte si no se toman las medidas pertinentes. Se han descrito lesiones de órganos huecos de la cavidad abdominal que suelen ser parte de una hernia diafragmática. Dentro de las lesiones esplácnicas en el abdomen más frecuentes están la hepática y la esplénica. Conclusiones: Estas lesiones son prevenibles y se debe tener en cuenta su mecanismo de producción para evitarlas. Para este fin recomendamos una selección cuidadosa del sitio de inserción, realizar una confirmación adecuada de la posición de la sonda, manipularla cuidadosamente y monitorear constantemente al paciente(AU)

Introduction: Chest tube insertion is a frequent surgical procedure that can have serious complications, which depend mostly on the practitioner's experience, the tube's size and the use of imaging to guide the insertion. Objective: To describe the main splanchnic injuries caused during chest tube insertion, as well as to present algorithms for early diagnosis and timely treatment of these types of iatrogeny. Methods: A descriptive narrative review was performed during the first quarter of the year 2023. The electronic databases PubMed, LILACS, EBSCO and Cochrane were used. Articles published from 1984 to 2022 were reviewed. Most of the information was secured to be framed within a period of no more than 10 years. Development: Among the splanchnic injuries within the thoracic cavity, lung injury is the most frequent and may lead to bleeding or persistent air leak. Vascular injuries are severe and can lead to death if appropriate measures are not taken. Injuries to hollow organs of the abdominal cavity have been described to be usually part of a diaphragmatic hernia. Among the most frequent splanchnic lesions within the abdomen are the hepatic and splenic injuries. Conclusions: These lesions are preventable and their mechanism of production should be taken into account in order to avoid them. To achieve this, we recommend that the insertion site be carefully selected and that the tube's position be adequately confirmed, as well as the careful handling of the tube and the constant monitoring of the patient(AU)

Suspected systemic gas embolism associated with lung tissue perforation caused by a previously inserted chest drain in a dog.

OBJECTIVE: To report a case of systemic gas embolism associated with removal of a chest drain perforating a lung lobe in a dog undergoing sternotomy under general anesthesia and intermittent positive pressure ventilation. CASE SUMMARY: An 8-year-old Cocker Spaniel underwent an exploratory thoracotomy via median sternotomy for surgical management of pyothorax that was treated conservatively for 7 days prior to referral following bilateral chest drain placement. The surgical procedure consisted of a subphrenic mediastinectomy and pericardiectomy. During surgery, it became apparent that the right drain was perforating the right middle lung lobe. Sudden desaturation and rapid hemodynamic deterioration occurred after the drain was removed. A systemic gas embolism was suspected on the basis of clinical signs and results of an arterial blood gas analysis, and immediate supportive treatment was started with an adequate response. Once the surgical procedure was completed, a clear "mill wheel" sound was audible on cardiac auscultation and point-of-care cardiac ultrasound confirmed the presence of gas bubbles in the cardiac chambers. The dog recovered from anesthesia and was managed in the intensive care unit where arterial blood gas analyses were nearly normal and the dog made a full recovery. NEW OR UNIQUE INFORMATION PROVIDED: In people, there are reports of fatal air embolism related to the use of chest drains. To our knowledge, this is the first case report in dogs of a systemic gas embolism during open-chest surgery caused by a chest drain perforating a lung lobe. Immediate recognition and aggressive treatment of this life-threatening condition should be provided in order to achieve a favorable outcome.

[Uniportal thoracoscopic thorough debridement for tubercular empyema with abscess of the chest wall].

Objective: To examine the feasibility and technical considerations of thorough debridement using uniportal thoracoscopic surgery for tuberculous empyema complicated by chest wall tuberculosis. Methods: A retrospective analysis was conducted on 38 patients who underwent comprehensive uniportal thoracoscopy debridement for empyema complicated by chest wall tuberculosis in the Department of Thoracic Surgery, Shanghai Pulmonary Hospital, from March 2019 to August 2021. There were 23 males and 15 females, aged (M(IQR)) 30 (25) years (range: 18 to 78 years). The patients were cleared of chest wall tuberculosis under general anesthesia and underwent an incision through the intercostal sinus, followed by the whole fiberboard decortication method. Chest tube drainage was used for pleural cavity disease and negative pressure drainage for chest wall tuberculosis with SB tube, and without muscle flap filling and pressure bandaging. If there was no air leakage, the chest tube was removed first, followed by the removal of the SB tube after 2 to 7 days if there was no obvious residual cavity on the CT scan. The patients were followed up in outpatient clinics and by telephone until October 2022. Results: The operation time was 2.0 (1.5) h (range: 1 to 5 h), and blood loss during the operation was 100 (175) ml (range: 100 to 1 200 ml). The most common postoperative complication was prolonged air leak, with an incidence rate of 81.6% (31/38). The postoperative drainage time of the chest tube was 14 (12) days (range: 2 to 31 days) and the postoperative drainage time of the SB tube was 21 (14) days (range: 4 to 40 days). The follow-up time was 25 (11) months (range: 13 to 42 months). All patients had primary healing of their incisions and there was no tuberculosis recurrence during the follow-up period. Conclusion: Uniportal thoracoscopic thorough debridement combined with postoperative standardized antituberculosis treatment is safe and feasible for the treatment of tuberculous empyema with chest wall tuberculosis, which could achieve a good long-term recovery effect.

Does preinjury anticoagulation worsen outcomes among traumatic hemothorax patients? A nationwide retrospective analysis.

INTRODUCTION: Up to a quarter of all traumatic deaths are due to thoracic injuries. Current guidelines recommend consideration of evacuation of all hemothoraces with tube thoracostomy. The aim of our study was to determine the impact of pre-injury anticoagulation on outcomes of traumatic hemothorax patients. MATERIALS AND METHODS: We performed a 4-year (2017 - 2020) analysis of the ACS-TQIP database. We included all adult trauma patients (age ≥18 years) presenting with hemothorax and no other severe injuries (other body regions <3). Patients with a history of bleeding disorders, chronic liver disease, or cancer were excluded from this study. Patients were stratified into two groups based on the history of preinjury anticoagulant use (AC, preinjury anticoagulant use: No-AC, no preinjury anticoagulant use). Propensity score matching (1:1) was done by adjusting for demographics, ED vitals, injury parameters, comorbidities, thromboprophylaxis type, and trauma center verification level. Outcome measures were interventions for hemothorax (chest tube, video-assisted thoracoscopic surgery [VATS]), reinterventions (chest tube > once), overall complications, hospital length of stay (LOS), and mortality. RESULTS: A matched cohort of 6,962 patients (AC, 3,481; No-AC, 3,481) was analyzed. The median age was 75 years, and the median ISS was 10. The AC and No-AC groups were similar in terms of baseline characteristics. Compared to the No-AC group, AC group had higher rates of chest tube placement (46% vs 43%, p = 0.018), overall complications (8% vs 7%, p = 0.046), and longer hospital LOS (7[4-12] vs 6[3-10] days, p ≤ 0.001). Reintervention and mortality rates were similar between the groups (p>0.05). CONCLUSION: The use of preinjury anticoagulants in hemothorax patients negatively impacts patient outcomes. Increased surveillance is required while dealing with hemothorax patients on pre-injury anticoagulants, and consideration should be given to earlier interventions for such patients.

A series of experiences with TissuePatch™ for alveolar air leak after pulmonary resection.

OBJECTIVES: Prolonged air leak after pulmonary resection strongly influences chest tube duration and hospitalization. This prospective study aimed to report a series of experiences with a synthetic sealant (TissuePatch™) and compare them with a combination covering method (polyglycolic acid sheet + fibrin glue) for air leaks after pulmonary surgery. METHODS: We included 51 patients (age: 20-89 years) who underwent lung resection. Patients who presented with alveolar air leak during the intraoperative water sealing test were randomly assigned to the TissuePatch™ or combination covering method groups. The chest tube was removed when there was no air leak over a period of 6 h, and no active bleeding under continuous monitoring using a digital drainage system. The chest tube duration was assessed, and various perioperative factors (such as the index of prolonged air leak score) were evaluated. RESULTS: Twenty (39.2%) patients developed intraoperative air leak; ten patients received TissuePatch™; and one patient who was receiving TissuePatch™ switched to the combination covering method because of broken TissuePatch™. The chest tube duration, index of prolonged air leak score, prolonged air leak, other complications, and postoperative hospitalization in both groups were similar. No TissuePatch™-related adverse events were reported. CONCLUSIONS: Results from the use of TissuePatch™ were almost similar to those associated with the use of combination covering method in preventing prolonged postoperative air leak after pulmonary resection. Randomized, double-arm studies are required to confirm the efficacy of TissuePatch™ observed during this study.

Comparison of post-operative and pulmonary morbidity due to subxiphoid and midaxillary chest drainage tubes after coronary artery bypass grafting.

AIM: pain and pulmonary morbidity in patients who underwent coronary artery bypass grafting (CABG) using left internal thoracic artery (LITA) grafting. MATERIAL AND METHOD: The study was prospective and included 40 patients who underwent elective isolated CABG with pedicled LITA grafts. Patients were divided into two groups according to the method used to place chest drainage tubes. Group 1 (n=20) had the left chest drain tube inserted through the sixth intercostal space along the anterior axillary line (mid-axillary approach), and Group 2 (n=20) had the left chest drain tube inserted through the midline inferior to the xiphoid process (subxiphoid approach). We evaluated the groups in terms of postoperative pain, pulmonary morbidity, amount of chest tube drainage, need for analgesic agents, and length of hospital stay. RESULTS: In group 1, the pain was significantly higher during mobilization and drain removal (p<0.05) but was similar at rest. In Group 1 and Group 2, pulmonary morbidity rates were statistically similar for pleural effusion (2 vs. 5; p=0.40), atelectasis (2 vs. 5; p=0.40), and pneumothorax after drain removal (1 vs. 0; p=1.00). Two of the patients with pleural effusion in Group 2 underwent thoracentesis. There was no difference between the two groups regarding the amount of chest tube drainage, cumulative doses of an analgesic agent, and length of hospital stay (p>0.05). CONCLUSION: According to these results, both procedures can be used safely for chest drainage tube placement after CABG. KEY WORDS: Chest Pain, Chest Tubes, Coronary Artery Bypass, Complications, Drainage, Postoperative.

Early Water Seal of Chest Tubes Following Video-Assisted Thoracic Surgery Pleurodesis.

INTRODUCTION: Early water seal following minimally invasive pulmonary lobectomy has been shown to reduce chest tube duration and postoperative length of stay (LOS). We evaluated chest tube duration and postoperative LOS following a standardized chest tube management protocol change (water seal on postoperative day 1) after video-assisted thoracic surgery (VATS) pleurodesis. METHODS: We identified adult patients undergoing VATS pleurodesis from August 2013 to December 2021. The chest tube protocol was changed in January 2017 such that patients were placed to water seal on the morning of postoperative day 1. Patients were divided into two groups, before the change (Group 1: August 2013-December 2016) and after (Group 2: January 2017-December 2021). We compared demographics, clinical characteristics, operative details, postoperative chest tube duration and output, and postoperative LOS between the groups. Descriptive statistics and log-transformed multivariable linear regression models were used to identify differences in patient outcomes that were associated with the protocol change. RESULTS: A total of 488 patients underwent VATS pleurodesis during the study period (Group 1: 329 patients; Group 2: 159 patients). The median age was 61 y (interquartile range [IQR] 49-68), 51% were females, 69% were White, and 29% were Black. For postoperative LOS, Group 1 had an IQR of 3-7 d, while Group 2 had an IQR of 2-6 d (P < 0.001). The multivariable log-transformed linear regression models demonstrated that the practice change was associated with reduced chest tube duration (0.77 times the chest tube duration before the change; P < 0.001) and reduced LOS (0.81 times the LOS before the change; P = 0.006). There was an associated reduction in patients needing to return to the operating room (P = 0.048) and needing postoperative extended ventilatory support (P = 0.035). CONCLUSIONS: Development of a standardized protocol to water seal chest tubes on postoperative day 1 following VATS pleurodesis is associated with reduced chest tube duration and LOS without an increase in postoperative complication rates.

Misconnected chest tube: An extremely unusual fatal complication of secondary pneumothorax.

A rare and fatal complication of suction drainage of secondary spontaneous pneumothorax is reported. The patient, likely by a mistake, arbitrarily connected the oxygen supply tube to the thoracic drain. The sharp increase of intrapleural pressure combined with the atmospheric intraalveolar environment caused diffuse lung injury and cardiopulmonary collapse without a direct lung injury. The conflicting interests of patient autonomy and patient safety require further consideration.

Reintervention Rate After Pigtail Catheter Insertion Compared to Surgical Chest Tubes.

BACKGROUND: Prior studies suggest similar efficacy between large-bore chest tube (CT) placement and small-bore pigtail catheter (PC) placement for the treatment of pleural space processes. This study examined reintervention rates of CT and PC in patients with pneumothorax, hemothorax, and pleural effusion. METHODS: This retrospective study examined patients from September 2015 through December 2020. Patients were identified using ICD codes for pneumothorax, hemothorax, or pleural effusion. Use of a pigtail catheter (≤14Fr) or surgical chest tube (≥20Fr) was noted. The primary outcome was overall reintervention rate within 30 days of tube insertion. Patients who died with a pleural drainage catheter in place, unrelated to complications from chest tube placement, were excluded. RESULTS: There were 1032 total patients in the study: 706 CT patients and 326 PC patients. The PC group was older with more comorbidities and more likely to have effusion as the indication for pleural drainage. Patients with PC were 2.35 times more likely to have the tube replaced or repositioned (P < .0001), 1.77 times more likely to require any reintervention (P = .001) and 2.09 times more likely to remain in the hospital >14 days (P < .0001) compared to patients with CT. CONCLUSION: PCs have a significantly higher reintervention rate compared to CT for the treatment of pneumothorax, hemothorax, and pleural effusion. Although PC are believed to cause less pain and tissue trauma, they do not necessarily drain the pleural space as well as CT. Decisions on which method of draining the chest should be made on a case-by-case basis.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults.

INTRODUCTION: We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy. METHODS: In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique. RESULTS: Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85). CONCLUSIONS: There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Association between bacterial growth in chest tube and anastomotic leakage after esophageal resection: prospective cohort study.

PURPOSE: The aim of this study was to examine whether collagenase producing bacteria could be detected, in fluid collected from chest tubes, before clinical presentation of anastomotic leakage after esophageal resection. METHODS: We conducted a prospective single-center study of patients who underwent resection of the gastroesophageal junction. All patients had a chest tube placed in the pleural cavity perioperatively. Drain fluid was collected and cultured from the first post-operative day and at time of routine removal of the drain (days 3-5). RESULTS: From January 2018 to July 2019, a total of 84 patients were included in the study. Twenty (36%) patients experienced severe complications with a Clavien-Dindo score of 3b-5. Eleven (13%) patients were diagnosed with anastomotic leakage which occurred after 8 days (mean, range 2-13). Twenty patients (24%) had drain samples with significant growth of microbes. Among the 11 patients with anastomotic leakage, we found 2 with microbe growth at POD 2 and POD 4, the remaining 9 samples were negative (p = 0.638). Thirty-day mortality rate was zero. CONCLUSION: Cultured fluid from the pleural cavity of asymptomatic patients following esophageal resection did not indicate a significant association with anastomotic leakage.

Drainless thoracoscopic surgery should be avoided in primary spontaneous pneumothorax with pleural adhesion.

OBJECTIVES: Drainless thoracoscopic surgery, defined by omitting chest drain after surgery, has been demonstrated to be feasible in selected patients for pulmonary resection. However, drainless procedure for the treatment of primary spontaneous pneumothorax has raised concerns for its safety and thus has been less often reported. We aimed to share our preliminary experience regarding how to select patients with spontaneous pneumothorax for this procedure. METHODS: A retrospective study recruiting 303 consecutive patients with the diagnosis of spontaneous pneumothorax undergoing thoracoscopic surgery in our centre from August 2016 to June 2020 was done. After careful selection, the chest drain was omitted in selected patients who underwent non-intubated uniportal thoracoscopic surgery. Patients' clinical characteristics and perioperative outcomes were analysed. RESULTS: A total of 34 patients underwent drainless thoracoscopic surgery for the treatment of spontaneous pneumothorax. Pleural adhesion was noted in 9 patients during surgery, and all of them (100%) developed residual pneumothorax, among which intercostal drainage was required in 2 (22.2%) patients and ipsilateral pneumothorax recurred 3 years after surgery in 1 (11.1%) patient. Among the remaining 25 without pleural adhesion, 17 (68.0%) developed minor residual pneumothorax (P = 0.006), which all resolved spontaneously within 1-2 weeks, with no complications or recurrence during postoperative follow-up for at least 2 years. CONCLUSIONS: Drainless thoracoscopic surgery for the treatment of primary spontaneous pneumothorax is feasible but can be risky without careful patient selection. In our experience, the drainless procedure should be avoided in patients with identifiable pleural adhesion noted during surgery.