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Ann Thorac Surg 1998;66:1751-1754
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung

^a Allegheny General Hospital Campus, Allegheny University of the Health Sciences, Pittsburgh, Pennsylvania, USA
^b St. Louis University Medical Center, St. Louis, Missouri, USA
^c Cardiothoracic Surgical Associates of North Texas, Dallas, Texas, USA

Address reprint requests to Dr Landreneau, General Thoracic Surgery, Allegheny University of the Health Sciences, Third Floor-South Tower, Allegheny General Hospital, 490 East North Ave, Pittsburgh, PA 15212

Presented at the Poster Session of the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

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Background. Traditional management of chest tubes after a wedge resection of peripheral pulmonary tissue often lasts several days. We evaluated the safety and efficacy of early chest tube removal in the recovery room after uncomplicated video-assisted thoracoscopic surgical wedge resections of the lung.

Methods. From December 1995 to July 1997, 59 patients underwent video-assisted thoracoscopic surgical wedge resection for indeterminate pulmonary nodules (n = 33) or interstitial lung disease (n = 26). We prospectively evaluated early chest tube removal in the last 33 patients; 18 patients with nodules and 15 with interstitial lung disease. Patients who were in the early removal group had chest tubes removed within 90 minutes of the surgical procedure. Criteria for early removal were established and met before chest tube removal. There was no difference between groups with respect to age, sex, comorbidities, or pathologic evaluation of resection specimens.

Results. Ninety-four percent (31 of 33) of patients considered for early chest tube removal met criteria for immediate tube removal. Air leak and excessive drainage prohibited early removal in 2 patients. Patients who were managed traditionally averaged 3.3 days with chest tubes—1.8 days on suction, 1.3 days on water seal. Patients who had early removal of their chest tubes had a shorter postoperative stay (2.0 ± 1.0 versus 3.9 ± 2.1 days, p = 0.001) and fewer chest roentgenograms (2.8 ± 2.1 versus 5.1 ± 2.0, p = 0.001). There were no differences in complications including small pneumothoraces (5 in the early removal group, 7 in the traditional management group), which were managed with observation alone. Total narcotic requirements were greater in the traditional management group (54 ± 44.8 versus 24.6 ± 22.9 morphine milligram equivalents, p = 0.005).

Conclusions. Early chest tube removal after video-assisted thoracoscopic surgical wedge resection of peripheral pulmonary tissue appears to be a safe and cost-effective practice if strict criteria for removal are met.

	Introduction

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Traditional management (TM) of chest tubes after wedge resection of peripheral pulmonary tissue often lasts for days. The usual approach to chest tube management involves a period of applied suction followed by water seal drainage before chest tube removal. This strategy was developed over many years for patients undergoing a major pulmonary resection through thoracotomy incisions, but it may not be necessary for all patients. Some surgeons have modified their management of chest tubes by removing them on the first postoperative day if no air leaks are present [1, 2].

Video-assisted thoracoscopic surgery (VATS) appears to result in less chest wall trauma than traditional thoracotomy, and the incidence of pulmonary parenchymal air leaks appears to be small with the use of modern endoscopic stapling devices. We believed it reasonable to consider chest tube removal early after VATS wedge resection of peripherally located pulmonary parenchymal disease. This study examines the relative safety and efficacy of this approach of early chest tube removal (ER) compared with TM after VATS wedge resection of the lung.

	Methods

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From December 1995 to July 1997, 59 patients underwent VATS wedge resection for indeterminate pulmonary nodules or interstitial lung disease. No further resection was used for these patients. A diagnosis of benign or malignant disease was determined with an intraoperative frozen section. Metastatic lesions or limited cardiopulmonary reserve precluded anatomic resection in those patients with malignant disease. Among the last 33 patients, we prospectively evaluated ER for chest tube management after VATS wedge resection. To establish the safety and efficacy of ER after VATS wedge resection, we established clinical criteria for this ER strategy as follows.

1. Peripherally located disease
   
2. Absence of extensive adhesions or visceral pleural disruption
   
3. No obvious air leaks during operation
   
4. Complete expansion of the lung on postoperative chest roentgenogram
   
5. Drainage 50 mL/h
   
6. Extubation before chest tube removal
   
7. Absence of an air leak in the recovery room
   

The records of 26 patients who underwent VATS resection with similar peripheral pulmonary disease (15 with nodules and 11 with interstitial lung disease) and had TM of their chest tubes were also reviewed. All operations were elective in nature and none of the patients undergoing biopsy for the determination of their interstitial lung disease were ventilator-dependent. All ER patients had their chest tubes removed within 90 minutes of the operation while in the recovery room. Table 1 profiles the patient demographic characteristics of both treatment groups. There was no difference between groups with respect to age, sex, comorbidities, or disease of resection specimens.

View larger version (100K): [in this window] [in a new window]   Fig 1. Computed tomographic scan showing indeterminate peripheral pulmonary nodule in the left lung.

View larger version (100K): [in this window] [in a new window]   Fig 2. Computed tomographic scan showing deep indeterminate pulmonary nodule in the right lung. This type of lesion is often not amenable to video-assisted thoracoscopic surgical wedge resection.

View larger version (77K): [in this window] [in a new window]   Fig 3. Computed tomographic scan showing extensive infiltrative pulmonary lesion in the right lung. Because of induration and loss of visceral pleural integrity this patient would not be considered for early chest tube removal after video-assisted thoracoscopic surgical wedge resection.

View larger version (139K): [in this window] [in a new window]   Fig 4. Computed tomographic scan showing diffuse interstitial lung disease.

Postoperative assessment
A chest roentgenogram (CXR) was obtained shortly after transfer to the postoperative recovery room in all 59 patients. Among the 33 ER patients, chest tubes were removed within 90 minutes of surgery if the lung was completely expanded on CXR, the chest tube drainage was minimal, and there was an absence of parenchymal air leak. A follow-up CXR was then obtained 4 to 6 hours later to confirm complete lung expansion. Records of the 26 patients who had undergone VATS resection and had TM of their chest tubes were also reviewed. The primary end points assessed for the ER and TM groups were the relative occurrence of postoperative complications (including pneumothorax), the length of hospital stay, and the number of postoperative CXRs obtained during the hospitalization. The total narcotic analgesic requirement, tabulated as morphine milligram equivalents per day, was also assessed to roughly determine differences in postoperative pain management needs.

	Results

Top Abstract Introduction Methods Results Comment References

 
Ninety-four percent (31 of 33) of patients considered for ER met criteria for early tube removal (an intent to treat). An air leak and excessive chest tube drainage prohibited early removal in 2 patients. Both of these patients who were considered for ER had undergone VATS wedge resection of pulmonary parenchymal nodules.

Chest tube duration among the patients undergoing TM of their chest tubes averaged 3.3 days. Chest tubes were maintained an average of 1.8 days on suction and 1.3 days of water seal drainage (Fig 5). Patients undergoing ER management had a shorter postoperative stay (2.0 ± 1.0 versus 3.9 ± 2.1 days, p = 0.001) and underwent fewer postoperative CXRs (2.8 ± 21. versus 5.1 ± 2.0, p = 0.001). After discharge no patient required readmission or additional CXRs before routine follow-up at 3 weeks.

View larger version (12K): [in this window] [in a new window]   Fig 5. Chest tube duration. The early removal group had their chest tubes removed within 90 minutes of operation. The traditional management group had their chest tubes maintained an average of 1.8 days on suction and 1.3 days on water seal.

	Comment

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A surgical procedure is often indicated for the diagnosis of an indeterminate pulmonary nodule and to assist in directing medical therapy for patients with interstitial lung disease. Video-assisted thoracoscopic surgery has become an important tool in this setting [9, 10]. Although the cost-effectiveness of VATS has been debated [11, 12], the safety and efficacy have been established [3, 8, 10]. Until the development of the thoracoscopic wedge resection technique, most diagnostic lung biopsies were obtained by means of an open thoracotomy. Despite the benefits of VATS, such as less pain, smaller incisions, and less trauma, some thoracic surgeons have been reluctant to alter chest tube management from that used for an open pulmonary resection. Accordingly, our practice had been to keep the chest tubes inserted at operation for at least 24 hours. The data presented here show that chest tubes can be safely removed shortly after operation if certain criteria are met. This practice of ER allows for earlier patient ambulation and discharge from the hospital. In addition, fewer postoperative CXRs may be required, and less overall narcotic analgesia needed, compared with "standard" chest tube management after VATS wedge resection of the lung.

Some surgeons believe that leaving the chest tube in place for 24 hours provides a "safety net" and will reduce the incidence of early postoperative complications such as pneumothorax or retained hemothorax. The findings of this study do not support this argument. Also, it may be true that maintaining a tube for a longer time may result in misinterpretation of the significance of the drainage (ie, augmented drainage resulting from negative pressure applied to the chest tube system). Busy thoracic services may also become distracted by the hectic nature of their day and unintentionally further delay chest tube removal when they rely on conventional management approaches. In fact, it is now our belief that the longer most chest tubes are in, the longer they stay in place, whether they are needed or not.

This study does not address the issue of chest tube removal after major pulmonary resection, and the strategy of ER management in this setting may not apply. We conclude, however, that ER after VATS wedge resection of peripheral pulmonary pathology appears to be a safe and cost-effective practice if strict criteria are met.

	References

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1. Dowling R.D., Landreneau R.J., Magee M., Keenan R.J., Ferson P.F. Thoracoscopic wedge resection of the lung. Surg Rounds 1993;16:341-349.
2. Gaensler E.A., Carrington C.B. Open biopsy for chronic diffuse infiltrative lung disease: clinical, roentgenographic, and physiological correlations in 502 patients. Ann Thorac Surg 1980;30:411-426.[Abstract/Free Full Text]
3. Mitruka S., Landreneau R.J., Mack M.J., et al. Diagnosing the indeterminate pulmonary nodule: percutaneous biopsy versus thoracoscopy. Surgery 1995;118:676-684.[Medline]
4. Landreneau R.J., Mack M.J., Keenan R.J., Hazelrigg S.R., Dowling R.D., Ferson P.F. Strategic planning for video-assisted thoracic surgery. Ann Thorac Surg 1993;56:615-619.[Abstract/Free Full Text]
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