The use of small-bore wire-guided chest drains for the management of feline pyothorax: A retrospective case series.

Background: Pyothorax in cats is routinely managed, at least initially, with thoracic tube placement associated with systemic antimicrobial administration. Traditionally, large-bore trocar-type thoracostomy tubes have preferentially been used for the drainage of thick material from the pleural space. In recent years, the use of small-bore wire-guided thoracic drains has increased in both small animals and in humans. Few studies have highlighted the efficacy of small-bore wire-guided thoracostomy tubes. Aim: The purpose of this study was to describe the use of small-bore wire-guided thoracostomy tubes in feline pyothorax in terms of efficacy, safety, and outcome. Methods: Cats with pyothorax managed with small-bore thoracostomy tubes (SBTTs) (2015-2018) were retrospectively studied. The number of drains inserted, the need for anesthesia and analgesia for chest tube placement and maintenance, and related major and minor complications were reviewed. Clinical data, diagnostic results, treatment, and outcome were recorded. Results: Ten cats were enrolled. Thoracostomy tube placement was unilateral in 7/10 cats, despite the presence of bilateral effusion in 9/10 cats, and required sedation (8/10) or anesthesia (2/10). Three cats experienced minor complications during the chest tube insertion, including self-limiting pneumothorax (1/3) and malpositioning (2/3). One cat had a major complication (non-functional malposition) requiring reposition of the drain. Pain management was adequately achieved using opioids (8/10) or opioids plus nonsteroidal anti-inflammatory drugs (2/10). Partial chest tube occlusion occurred in three cases and it was resolved with lavage. In one case, the occlusion was complete, requiring drain removal. Three out of 10 cats were treated medically, combining thoracostomy tubes and antibiotics, while 7/10 cats underwent surgery. All the cats survived. Conclusion: SBTTs represent a safe and effective option for the initial management of feline pyothorax. In fact, mainly minor complications were reported during insertion and usage. The SBTTs were well tolerated by the cats with a satisfactory performance in terms of exudate drainage in most cases. The combined use of a small-bore thoracostomy drain together with the common practice of surgical treatment might have resulted in the successful management of the cases presented.

Pediatric Spontaneous Pneumothorax: Does Initial Treatment Affect Outcomes?

BACKGROUND: Primary spontaneous pneumothorax (PSP) commonly occurs in adolescents, most commonly in males, and has recurrence rates between 20% and 60%. Surgical therapy has long been debated regarding its role in preventing recurrence, with no current consensus on guidelines for care. The purpose of this study is to examine the effect of treatment type on recurrence rates in pediatric PSP. METHODS: This is a single-institution, institutional review board-approved retrospective analysis of patients aged 1 to 18 diagnosed with their first occurrence of PSP between 2009 and 2017. Patient demographics, hospital course, and outcomes over a 2-y period were collected. Patients were divided into nonoperative (oxygen therapy only) management, chest tube placement, and surgical management. The primary outcome was the recurrence rate. RESULTS: Sixty-four patients diagnosed with PSP met inclusive criteria. The mean age was 15.5, and 48 (75%) of patients were men. Twenty-one patients (33%) underwent nonoperative treatment, 24 patients (37.5%) underwent operative treatment with video-assisted thoracoscopic surgery or open thoracotomy, and 19 patients (30%) underwent chest tube or pigtail placement alone. Fifteen patients (23.4%) experienced a recurrence within 2 y: 6 patients (29%) from the nonoperative treatment group, 4 (21%) who were treated with the chest tube only, and 5 (21%) who underwent video-assisted thoracoscopic surgery or open thoracotomy. No statistically significant difference in recurrence rates was found between treatment groups. Pneumothorax size was found to differ between treatment type; larger pneumothoraces were more likely to undergo surgical intervention (P = 0.0003). Smaller pneumothoraces were associated with higher rates of recurrence on multivariate logistic regression analysis (P = 0.046). CONCLUSIONS: Recurrence of PSP in adolescents was found to be 23.4% after 2-y follow-up. Smaller-sized pneumothoraces were associated with higher rates of recurrence, but treatment type did not significantly affect recurrence rates.

Effect of puncture sites on pneumothorax after lung CT-guided biopsy.

To determine the influence of puncture site on aspiration in dealing with pneumothorax following CT-guided lung biopsy.Two hundred thirty-six pneumothorax patients after CT guided lung biopsies were retrospective analyzed from January 2013 to December 2018. Patients with minor asymptomatic pneumothorax were treated conservatively with monitoring of vital signs and follow-up CT to confirm stability. Ninety of the 236 pneumothorax patients, who underwent manual aspiration, were included in this analysis. In first manual aspiration, the needle from the lesion was retracted back into the pleural space after biopsy, and then aspiration treatment was performed. If the treatment is of unsatisfied result, a second attempt aspiration treatment, which puncture site away from initial biopsy one, was conducted. The efficacy of simple manual aspiration and the new method, changing puncture site for re-aspiration was observed.Immediate success was obtained in 62 out of the 90 patients in the first attempt. The effective rate and failure rate were 68.9% (62/90) and 31.1% (28/90), respectively. Twenty-eight patients in whom first attempt simple aspiration were unsuccessful underwent a second attempt aspiration, which puncture site away from initial biopsy one, was successful in 13 patients with 15 patients undergoing chest tube placement. The effective rate and failure rate were 46.4% (13/28) and 53.6% (15/28), respectively. Applying the modified procedure, total effective rate of aspiration elevated significantly from 68.9% (62/90) to 83.3% (75/90) (P < .05). No serious side effects were detected in the period of aspiration procedure.Manual aspiration with puncture site away from initial biopsy one is worth trying to deal with post-biopsy pneumothorax. This modified procedure improved the efficiency of treatment significantly, and reduced the rate of pneumothorax requiring chest tube placement.

Pleural Fluid suPAR Levels Predict the Need for Invasive Management in Parapneumonic Effusions.

Rationale: Parapneumonic effusions have a wide clinical spectrum. The majority settle with conservative management but some progress to complex collections requiring intervention. For decades, physicians have relied on pleural fluid pH to determine the need for chest tube drainage despite a lack of prospective validation and no ability to predict the requirement for fibrinolytics or thoracic surgery.Objectives: To study the ability of suPAR (soluble urokinase plasminogen activator receptor), a potential biomarker of pleural fluid loculation, to predict the need for invasive management compared with conventional fluid biomarkers (pH, glucose, and lactate dehydrogenase) in parapneumonic effusions.Methods: Patients presenting with pleural effusions were prospectively recruited to an observational study with biological samples stored at presentation. Pleural fluid and serum suPAR levels were measured using the suPARnostic double-monoclonal antibody sandwich ELISA on 93 patients with parapneumonic effusions and 47 control subjects (benign and malignant effusions).Measurements and Main Results: Pleural suPAR levels were significantly higher in effusions that were loculated versus nonloculated parapneumonic effusions (median, 132 ng/ml vs. 22 ng/ml; P < 0.001). Pleural suPAR could more accurately predict the subsequent insertion of a chest tube with an area under the curve (AUC) of 0.93 (95% confidence interval, 0.89-0.98) compared with pleural pH (AUC 0.82; 95% confidence interval, 0.73-0.90). suPAR was superior to the combination of conventional pleural biomarkers (pH, glucose, and lactate dehydrogenase) when predicting the referral for intrapleural fibrinolysis or thoracic surgery (AUC 0.92 vs. 0.76).Conclusions: Raised pleural suPAR was predictive of patients receiving more invasive management of parapneumonic effusions and added value to conventional biomarkers. These results need validation in a prospective multicenter trial.

Evaluation of risk factors in pneumothorax development after computerized tomography-guided transthoracic biopsy and management of complications.

AIMS: This study aims to discuss the relationship between complications and patient characteristics and lesion properties in the transthoracic fine needle aspiration biopsy (TTFNAB) procedures performed for lung lesions and the treatment applied in our clinic to eliminate these complications. METHODS: In this retrospective study conducted from July 2014 to August 2017, the CT-guided TTFNAB was performed on 186 patients (145 males, 41 females) who were considered to have malignancies on their clinical evaluation, CT, and PET CT results. RESULTS: After 186 CT-guided TTFNAB interventions, a total of 24 (12.9%) patients developed procedure-related pneumothorax. Of these patients, 7 had a limited and minimal pneumothorax and no treatment was required for them, while 17 had a large and increasing pneumothorax and manual air aspiration was performed with coaxial needle during the procedure. The number pleural transitions (OR 6.513; 95%, 2,529-16,771 P < 0.001), emphysematous lungs (OR 4.612; 95%, 1,852-11.487 P < 0.001), and the presence of a lesion unrelated to the pleura (OR 8.205; 95%, 3,162-21,291 P < 0.001) can form the basis for the development of a pneumothorax. CONCLUSION: The chances of developing pneumothorax after TTFNAB depend on number of pleural transition, emphysematous lungs, and non-pleural lesions. However, it is considered that procedures such as manual air aspiration and autologous blood patch may reduce the need for chest tube following the development of pneumothorax.

Efficacy of the tract embolization technique with gelatin sponge slurry to reduce pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy.

PURPOSE: To assess the efficacy of the tract embolization technique using gelatin sponge slurry after CT-guided lung biopsy to reduce pneumothorax and chest tube placement rates. MATERIALS AND METHODS: We retrospectively compared 231 CT-guided lung biopsies performed with the tract embolization technique using gelatin sponge slurry (treated group) with 213 biopsies performed without embolization (control group). All procedures were performed at our institution between January 2014 and September 2018 by one of three experienced interventional radiologists using a 19-gauge coaxial needle. Multivariate analysis was performed between groups for risk factors for pneumothorax and chest tube placement, including patient demographics and lesion characteristics. RESULTS: When comparing the two groups, there was no significant difference concerning age, gender, emphysema, lesion size, lesion location, lesion morphology, needle tract depth and biopsy-side down patient positioning. Compared to the control group, patients with gelatin sponge slurry tract embolization had statistically lower rates of pneumothorax (10% vs. 25.8%; p < 0.0001) and chest tube placement (3.5% vs. 12.2%; p = 0.0005). Using multiple logistic regression analysis, the only variable that had an influence on the pneumothorax rate was the group (OR 0.32, 95% CI 0.18-0.56, p < 0.0001), and the variables that had an influence on the chest tube insertion rates were the group (OR 0.21, 95% CI 0.08-0.51, p = 0.0006) and presence of emphysema (OR 3.50, 95% CI 1.53-8.03, p = 0.0031). CONCLUSIONS: Tract embolization technique using gelatin sponge slurry after percutaneous CT-guided lung biopsy significantly reduces pneumothorax and chest tube placement rates. LEVEL OF EVIDENCE: Level 3a.

Chest Tube Management Practices by Trauma Surgeons.

BACKGROUND: Chest tube (CT) placement is among the most common procedures performed by trauma surgeons; evidence guiding CT management is limited and tends toward thoracic surgery patients. The study goal was to identify current CT management practices among trauma providers. MATERIALS AND METHODS: We designed a Web-based multiple-choice survey to assess CT management practices of trauma providers who were active, senior, or provisional members (n = 1890) of the Eastern Association for the Surgery of Trauma and distributed via e-mail. Descriptive statistics were used. RESULTS: The response rate was 39% (n = 734). Ninety-one percent of respondents were attending surgeons, the remainder fellows or residents. Regarding experience, 36% of respondents had five or fewer years of practice, 54% 10 y or fewer, and 79% 20 y or fewer. Attendings were more likely than trainees to place pigtail catheters for stable patients with pneumothorax (PTX). Attendings with experience of <5 y were more likely to choose a pigtail than more experienced surgeons for elderly patients with PTX. Respondents preferred standard size CTs for hemothorax and unstable patients with PTX, and larger tubes for unstable patients with hemothorax. Most respondents (53%) perceived the quality of evidence for trauma CT management to be low and cited personal experience and training as the main factors driving their practice. CONCLUSIONS: Trauma CT management is variable and nonstandardized, depending mostly on clinician training and personal experience. Few surgeons identify their practice as evidence based. We offer compelling justification for the need for trauma CT management research to determine best practices.

The effect of intraparenchymal blood patching on the rate of pneumothorax in patients undergoing percutaneous CT-guided core biopsy of the lung.

PURPOSE: To assess the effect of intraparenchymal blood patching (IBP) as well as tumor- and operator-related risk factors on the rate of pneumothoraxes after percutaneous CT-guided core needle biopsy of the lung. MATERIALS AND METHODS: We performed a retrospective analysis of 868 CT-guided lung biopsies that were conducted at our institution between 2003 and 2018, of which 419 (48%) received an IBP. Outcome variable included the rates of pneumothorax and chest tube placement, as well as lesion size (<3 cm versus ≥3 cm long axis diameter), lesion depth (≤2 cm, >2-4 cm, >4-5 cm and >5 cm distance to the pleura), location within the lungs (upper lobe, lower lobe, middle lobe), needle caliber (13 G, 15 G, 17 G, 19 G), number of samples taken (1-3 versus ≥4 samples), and experience of the performing physician. RESULTS: The rate of pneumothorax was significantly (p < 0.05) lower in the group with IBP (10.7%) compared to the group without IBP (15.4%). The number of post-interventional chest tube placements was also lower in the IBP group (3.1% vs. 5.8%) but not statistically significant. The lesion size correlated negatively with the rate of pneumothoraxes, whereas in both groups (±IBP) lesions ≥ 3 cm showed a significantly lower rate of pneumothorax (p < 0.05). With increasing lesion depth, the pneumothorax rate increased with (p < 0.01) and without (p < 0.001) IBP. The rate of pneumothorax was significantly lower (p < 0.05) for 17 G needles with IBP, but not for other calibers. For biopsies in the lower lobe, the pneumothorax rate reduced significantly (p < 0.001) with IBP. In case of ≥4 tissue samples, the pneumothorax rate was significantly lower with IBP (p < 0.01). For experienced operators, the overall pneumothorax rate was significantly lower compared to less experienced operators (p < 0001). CONCLUSIONS: IBP significantly reduces the rate of pneumothorax following CT-guided lung biopsies in particular for lesions located deeper in the lungs, when ≥4 samples are taken, when samples are taken by less-experienced operators, and when sampling from the lower lobes.

CT-guided Lung Biopsy: Effect of Biopsy-side Down Position on Pneumothorax and Chest Tube Placement.

Background Supine or prone positioning of the patient on the gantry table is the current standard of care for CT-guided lung biopsy; positioning biopsy side down was hypothesized to be associated with lower pneumothorax rate. Purpose To assess the effect of positioning patients biopsy side down during CT-guided lung biopsy on the incidence of pneumothorax, chest drain placement, and hemoptysis. Materials and Methods This retrospective study was performed between January 2013 and December 2016 in a tertiary referral oncology center. Patients undergoing CT-guided lung biopsy were either positioned in (a) the standard prone or supine position or (b) the lateral decubitus position with the biopsy side down. The relationship between patient position and pneumothorax, drain placement, and hemoptysis was assessed by using multivariable logistic regression models. Results A total of 373 consecutive patients (mean age ± standard deviation, 68 years ± 10), including 196 women and 177 men, were included in the study. Among these patients, 184 were positioned either prone or supine depending on the most direct path to the lesion and 189 were positioned biopsy side down. Pneumothorax occurred in 50 of 184 (27.2%) patients who were positioned either prone or supine and in 20 of 189 (10.6%) patients who were positioned biopsy side down (P < .001). Drain placement was required in 10 of 184 (5.4%) patients who were positioned either prone or supine and in eight of 189 (4.2%) patients who were positioned biopsy side down (P = .54). Hemoptysis occurred in 19 of 184 (10.3%) patients who were positioned prone or supine and in 10 of 189 (5.3%) patients who were positioned biopsy side down (P = .07). Prone or supine patient position (P = .001, odds ratio [OR] = 2.7 [95% confidence interval {CI}: 1.4, 4.9]), emphysema along the needle path (P = .02, OR = 2.1 [95% CI: 1.1, 4.0]), and lesion size (P = .02, OR = 1.0 [95% CI: 0.9, 1.0]) were independent risk factors for developing pneumothorax. Conclusion Positioning a patient biopsy side down for percutaneous CT-guided lung biopsy reduced the incidence of pneumothorax compared with the supine or prone position. © RSNA, 2019.

Progel Use is Not Associated with Decreased Incidence of Postoperative Air Leak after Nonanatomic Lung Surgery.

CONTEXT: Progel Pleural Air Leak Sealant (CR Bard, Warwick, RI) is a US Food and Drug Administration-approved hydrogel designed for application to surgical staple lines to prevent air leak after lung surgery. This product has demonstrated efficacy in reducing intraoperative air leaks compared with standard air leak closure methods. However, the impact on chest tube duration and length of hospital stay has not been reported. OBJECTIVE: To evaluate the effect on rates of postoperative air leak, chest tube duration, and hospital stay in surgical patients with and without use of Progel. DESIGN: Retrospective study of 176 patients aged 18 to 80 years who underwent video-assisted thoracoscopic wedge resections between 2014 and 2016. Eighty-four (48%) cases using Progel were included, as well as a representative sample of non-Progel cases (n = 92; 52%). MAIN OUTCOME MEASURE: Presence of postoperative lung air leak. RESULTS: No difference existed between the Progel and non-Progel groups in the rate of postoperative air leak (20/84, 23.81% Progel; 16/92, 17.39% non-Progel; p = 0.33). The length of time patients had a chest tube was similar (23.5 vs 23 hours, p = 0.721), as was percentage of patients with a less than 2-day hospitalization (77.17% non-Progel vs 82.14% Progel, p = 0.414). CONCLUSION: Our results suggest that Progel, used routinely in patients undergoing nonanatomic lung resection, does not have a significant impact on postoperative air leak, chest tube duration, or length of hospital stay. Further studies are warranted to evaluate the utility of Progel in reducing postoperative complications after thoracoscopic wedge resection in those treated for air leak or in the reduction of postoperative air leak in high-risk patients.

[Different approaches to chest drainage in the management of primary spontaneous pneumothorax]. / Facteurs influençant la réussite du drainage pleural d'un premier épisode de pneumothorax spontané primitif.

Drainage of primary spontaneous pneumothorax (PSP) may be managed by different techniques and with different types of drain. It is mainly performed in the pneumology department or in the emergency department. The aim of the study was to evaluate the factors that influence the success of PSP drainage. This retrospective, monocentric study performed in University Hospital of Toulouse, included patients with a first episode of PSP requiring drainage. The primary outcome was the rate of success according to the techniques of drainage. Data on the size of the drain (>14F or<14F), the drainage technique (small bore catheter or chest tube drainage) and the drainage department (pneumology or emergency) were collected. One hundred and twenty-four patients had a drainage between 2014 and 2016: the late recurrence free success rate was 59% (n=73). Compared with emergency, drainage in pneumology increased the success rate threefold regardless of the drainage technique (P=0.0001) The success rate was similar whatever the technique used (Seldinger or classic technique) (P=0.31). Success and complications rates were similar whether the drain was large (>14F) or small (<14F) (respectively P=0.99 and P=0.58). In our study, the drainage of PSP in the pneumology department, with a small caliber inserted by the Seldinger technique, was associated with a significantly higher success rate.

Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn.

BACKGROUND: Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It can be treated with either aspiration with a syringe (using a needle or an angiocatheter) or a chest tube inserted in the anterior pleural space and then connected to a Heimlich valve or an underwater seal with continuous suction. OBJECTIVES: To compare the efficacy and safety of needle aspiration (either with immediate removal of the needle or with the needle left in situ) to intercostal tube drainage in the management of neonatal pneumothorax (PTX). SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 4 June 2018), Embase (1980 to 4 June 2018), and CINAHL (1982 to 4 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax. DATA COLLECTION AND ANALYSIS: For each of the included trials, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.We used the GRADE approach to assess the quality of evidence. MAIN RESULTS: Two randomised controlled trials (142 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality when the needle was removed immediately after aspiration (risk ratio (RR) 3.92, 95% confidence interval (CI) 0.88 to 17.58; participants = 70; studies = 1) or left in situ (RR 1.50, 95% CI 0.27 to 8.45; participants = 72; studies = 1) or complications related to the procedure. With immediate removal of the needle following aspiration, 30% of the newborns did not require the placement of an intercostal tube drainage. None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is very low. AUTHORS' CONCLUSIONS: There is insufficient evidence to establish the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax. The two included trials showed no differences in mortality; however the information size is low. Needle aspiration reduces the need for intercostal tube drainage placement. Limited or no evidence is available on other clinically relevant outcomes.

A Pilot Study of Pulmonary Segmentectomy With Indocyanine Green Near-Infrared Angiography.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) pulmonary segmentectomy is commonly used in treating small ground-glass opacity (GGO) nodules in lung. The identification of the intersegmental plane is one of the challenges. In this pilot study, we aimed to evaluate the feasibility of indocyanine green (ICG) angiography in VATS segmentectomy. METHODS: Nineteen GGO patients were enrolled, and VATS segmentectomy with ICG near-infrared angiography were performed between July 2017 and December 2017. Conventional 3-port VATS was used. ICG was injected intravenously after dominant arties were ligated. Intersegmental plane was identified and divided by stapler and electrocautery. RESULTS: All patients had perfect intersegmental plane visualization. The mean operation time was 140.8 minutes, and the mean blood loss was 23.7 mL. No complications due to ICG occurred. The mean chest tube duration was 4.6 days. No severe complications occurred in the perioperative period. The mean chest tube drainage duration was 4.6 days. Prolonged postoperative air leak (>5 days), which required no surgical intervention, occurred in 2 cases. There were no severe complications or in-hospital deaths. CONCLUSIONS: VATS segmentectomy with ICG near-infrared angiography is a reasonable treatment option to treat small GGO in lung, especially due to its good surgical view maintenance.

Digital thoracic drainage: a new system to monitor air leaks in pediatric population.

INTRODUCTION: 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. METHOD: 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. RESULT: 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 ±â€¯0.6 in digital drainage group versus 5.38 ±â€¯4 days in traditional drainage group (p < 0.05) The mean number of postoperative radiographs was 2.8 ±â€¯1.1 in digital drainage group versus 6.23 ±â€¯5.2 radiographs in traditional drainage group (p < 0.05). The average hospital stay in digital drainage group was 5.69 ±â€¯2.7 days versus 7 ±â€¯4.7 days in the traditional drainage group (p > 0.05). No complications related to the use of digital drainage group were registered. CONCLUSION: 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. LEVEL OF EVIDENCE: II.

Timing of Fontan Completion in Children with Functionally Univentricular Hearts and Isomerism: The Impact of Age, Weight, and Pre-Fontan Arterial Oxygen Saturation.

Isomerism, or heterotaxy, impacts morbidity and mortality after various stages of univentricular palliation. Timing of Fontan completing in these patients based on preoperative factors has not been investigated previously. The aim of this study was to determine the impact of preoperative factors on various outcomes including length of hospital stay and duration of chest tubes. A cross-sectional study was conducted. Patients with isomerism having undergone Fontan at the Children's Hospital of Wisconsin between 1998 and 2014 were identified. Preoperative, operative, and postoperative data were collected on these patients. Linear regression analysis was conducted to determine preoperative characteristics associated with various postoperative outcomes. Receiver operator curve analysis was also performed to determine the sensitivity and specificity of age and pre-Fontan arterial oxygen saturation in predicting increased length of hospitalization and increased duration of chest tubes. Younger age and lower pre-Fontan arterial oxygen saturation were associated with increased length of hospitalization while younger age, lower pre-Fontan arterial oxygen saturation, interrupted inferior caval vein, and worse pre-Fontan atrioventricular valve regurgitation were associated with increased length of chest tubes. Age, arterial oxygen saturation, pulmonary arteriovenous malformations, interruption of the inferior caval vein, and atrioventricular valve regurgitation should all be taken into consideration when timing Fontan completion in patients with isomerism. Arterial oxygen saturations between 82 and 84% with an approximate age of 3 years appear to be a time at which it is reasonable to consider Fontan in patients with isomerism.

Video assisted thoracic surgery vs. thoracotomy for locally advanced lung squamous cell carcinoma after neoadjuvant chemotherapy.

BACKGROUND: Surgery is an important part of multidisciplinary treatment strategy for locally advanced lung squamous cell carcinoma (LSCC), but insufficient evidence supports the feasibility and safety of video assisted thoracic surgery (VATS) following neoadjuvant chemotherapy for locally advanced LSCC. This study aims to compare perioperative data and long-term survival of locally advanced LSCC patients between VATS and thoracotomy after neoadjuvant chemotherapy. METHODS: We retrospectively collected the clinical and pathological information of patients with locally advanced LSCC who underwent surgical resection after neoadjuvant chemotherapy from October 2013 to October 2017. All patients were divided into two groups (thoracotomy and VATS) and were compared the differences in perioperative, oncological and survival outcomes. RESULTS: A total of 81 patients were analyzed in this study (67 thoracotomy and 14 VATS). VATS provided less postoperative pain (P = 0.005) and produced less volume of chest drainage (P = 0.019) than thoracotomy, but the number of resected lymph nodes was less in VATS group (P = 0.011). However, there was no significant difference in the number of resected lymph node stations and the rate of nodal upstaging between two groups. The mean disease free survival (DFS) was 32.7 ± 2.7 months for the thoracotomy group and 31.8 ± 3.0 months for the VATS group (P = 0.335); the corresponding overall survival (OS) was 41.7 ± 2.2 months and 36.4 ± 4.1 months (P = 0.925). CONCLUSION: In selected patients with locally advanced LSCC, VATS played a positive role in postoperative recovery and associated similar survival outcome compared with thoracotomy after neoadjuvant chemotherapy.

Pilot evaluation of an objective structured assessment of technical skills tool for chest tube insertion.

Background: Chest tube insertion is a standard intervention for management of various injuries of the thorax. Efficient clinical training of this and similar bed-side procedures is equally demanded and improvable. Here, we propose a nouveau means of assessment and feedback using an Objective Structured Assessment of Technical Skills (OSATS) tool. The modified OSATS for chest drain insertion is evaluated in a pilot trial focusing on chest drain insertion. Methods: Participants in the pilot trial were medical students (3rd-6th year of studies, n=9), junior residents (1st-3rd post-graduate year, n=12), senior residents (4th-6th post-graduate year, n=14), and attending surgeons (n=6) from Heidelberg University. Chest drain insertions on a cadaveric porcine model were rated by experts with the modified OSATS score. Participants' performances were videotaped and subsequently rated by two remote experts (video rating). Primary aim was to assess criterion validity of the OSATS to distinguish experience levels. Results: Kruskal-Wallis test showed significant differences between means of scores between four groups stratified by previous experience in chest tube insertion (level 0: 22.1±3.2 vs. level 1: 26.8±2.8 vs. level 2: 35.4±2.2 vs. level 3: 41.0±2.0; p=0.002; p1,3=0.049, p0,3=0.005). However, if groups were stratified by formal professional level, no statistically significant distinction could be made using OSATS. Hence, the OSATS tool showed criterion validity for differentiation between experience levels. Conclusion: In the pilot study, the modified OSATS for chest tube insertion was apt to standardize expert rating and could be used to measure skill and to depict different experience levels. The OSATS will help facilitate training and assessment of chest drain insertion and could therefore improve surgical training for trauma situations. According to our data, the OSATS might be integrated into modern curricula.

Impact of Nesiritide Infusion on Early Postoperative Recovery After Total Cavopulmonary Connection Surgery.

OBJECTIVE: The purpose of the study is to compare the effects of nesiritide on the discharge time and pleural effusion in children with total cavopulmonary connection (TCPC), and to provide a more reasonable clinical method for these children. METHODS: Forty-four who children underwent cavopulmonary connection between January 2016 and 2017 were retrospectively collected, and 5 children were excluded from analysis due to postoperative thrombosis or second Fontan surgery due to high pulmonary hypertension. Thirteen children received nesiritide (3-11 days) plus conventional treatment as the nesiritide group, continuous infusion of nesiritide with the dose of 0.01 ug kg-1 min-1. Twenty-six children with the conventional treatment as the conventional treatment group. The length of stay in hospital and the retention time of chest drainage tube were compared between two groups. RESULTS: There were no significant differences in the time of cardiopulmonary bypass, postoperative ventilation time, ICU time, and vasoactive inotropic drug scores in the two groups. There were no hospital deaths in two groups. The median hospital stay was 20 days in the nesiritide group (11-56 days, means 25 days), and the median length of hospital stay was 28 days in the routine treatment group (9-95 days, means 34 days). There is no statistically significant difference between two groups with regard to the length of stay in hospital (P = 0.281). Regarding the thoracic drainage duration, the median was 17 days (9-55 days, means 22 days) in the nesiritide group and 23 days in the conventional treatment group (7-91 days, means 31 days) (P = 0.294). All the patients had no severe complications such as excessive fluid load, intractable hypotension, and liver or kidney injury. CONCLUSION: Nesiritide is safe in children who underwent cavopulmonary connection surgery. Compared with the conventional treatment group, postoperative nesiritide is not associated with improved early clinical outcomes after TCPC surgery.

Influence of factor XIII activity on post-operative transfusion in congenital cardiac surgery-A retrospective analysis.

OBJECTIVES: Coagulation factor XIII (FXIII) plays a key role in fibrin clot stabilization-an essential process for wound healing following cardiothoracic surgery. However, FXIII deficiency as a risk for post-operative bleeding in pediatric cardiac surgery involving cardiopulmonary bypass (CPB) for congenital heart disease (CHD) is controversially discussed. Thus, as primary outcome measures, we analyzed the association of pre-operative FXIII activity and post-operative chest tube drainage (CTD) loss with transfusion requirements post-operatively. Secondary outcomes included the influence of cyanosis and sex on transfusion. METHODS: Our retrospective analysis (2009-2010) encompassed a single center series of 76 cardio-surgical cases with CPB (0-17 years, mean age 5.61 years) that were post-operatively admitted to our pediatric intensive care unit (PICU). The observational period was 48 hours after cardiac surgery. Blood cell counts and coagulation status, including FXIII activity were routinely performed pre- and post-operatively. The administered amount of blood products and volume expanders was recorded electronically, along with the amount of CTD loss. Uni- and multivariate logistic regression analysis was performed to calculate the associations (odds ratios) of variables with post-operative transfusion needs. RESULTS: FXIII activities remained stable following CPB surgery. There was no association of pre- and post-operative FXIII activities and transfusion of blood products or volume expanders in the first 48 hours after surgery. Similarly, FXIII showed no association with CTD loss. Cyanosis and female sex were associated with transfusion rates. CONCLUSIONS: Although essentially involved in wound healing and clotting after surgery, FXIII activity does not serve as a valid predictor of post-operative transfusion need.