Ann Thorac Surg 1999;68:1376-1378
© 1999 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Selective use of chest tubes in thoracotomies for congenital cardiovascular procedures
Giorgio M. Aru, MDa,
Andrew P. Dabbs, MDa,
Erin R. Cummins, MDa,
William L. Reno, MDa,
Newt P. Harrison, MDa,
William P. English, MDa,
Bobby J. Heath, MDa
a Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
Address reprint requests to Dr Aru, Division of Cardiothoracic Surgery, University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216-4525
e-mail: garuteclink.net
Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14, 1998.
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Abstract
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Background. Advantages and complications have been reported from the use of chest tubes (CT). To reduce the incidence of complications we have employed a selective use of CT in thoracotomy for congenital cardiovascular procedure; ie, in absence of air leaks and fluid to be drained, no CT was inserted.
Methods. The lung was reexpanded and air evacuated during the chest closure. Early and 6 hours chest roentgenograms were performed on every patient. This study retrospectively reviews the results of this selective approach in 546 patients operated on between 1980 and 1998 mainly for patent ductus arteriosum ligation, pulmonary artery band, aortic coarctation, Blalock–Taussig shunt. Four hundred and eighteen patients did not receive a CT at the initial surgery (group I), and 128 patients received a CT either before or at surgery (group II).
Results. 40 patients in group I developed an air or fluid collection large enough to require a CT. Only one patient had complication, from an undetected hemothorax. Nine patients in group II required another CT, and one patient developed a pneumothorax upon pulling out the CT. No death in either group was related to the use or lack of use of the CT. A total of 378 CTs and collecting chambers were saved.
Conclusions. A selective approach to the use of CT in thoracotomies for cardiovascular procedures can be employed with minimal complications, more comfort for the patient, and cost savings.
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Introduction
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Chest tubes (CT) are traditionally used to either drain existing air or fluid, or to prevent their accumulation. Both advantages and complications have been reported from the use of CT. In order to reduce the incidence of complications, since 1980, we have employed a selective use of CT in congenital cardiovascular thoracotomy procedures; ie, in the absence of air or fluid to be drained, no CT was inserted and the patient was followed according to a strict protocol.
The lung was reexpanded and air evacuated during the chest closure. An immediate and 6-hour postop STAT chest radiograms (CXR) were performed in every patient.
This study retrospectively reviews the results of this selective approach in 546 consecutive patients operated on during a period of 18 years.
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Material and methods
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Between 1980 and 1998, 546 consecutive patients underwent thoracotomy for patent ductus arteriosum (PDA) ligation, pulmonary artery (PA) band, aortic coarctations (AoCoa) repair, and modified Blalock–Taussig shunt (BTS) or a combination of two or more of the above procedures. Of these, 418 patients (76.6% of the cases) did not receive a CT at the initial surgery (group I), and 128 patients (23.4%) received a CT either before or at surgery (group II). Reasons to insert a CT at surgery were either the presence of a visceral pleura tear, redo surgery, severe anasarca or bleeding diathesis. In absence of the above reasons, no CT was inserted and the following protocol was employed: Air was evacuated from the chest cavity with positive end expiratory pressure (PEEP) during the chest closure, ie, during tying the pericostal stitches and suturing the muscle layers, CXR were done immediately and again at 6 hours following surgery and checked by a surgeon, and the patient was clinically evaluated periodically by the surgeon and the nursing staff. The charts of all the patients were reviewed together with all the radiologic reports. Data collection was complete with one exception of weight and/or age of 9 patients.
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Results
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Groups I and II differ in age and weight, with a younger and smaller population in group I, and had a different proportion of the various procedures (Tables 1). Selective use of CT in group I:
| PDA |
183 |
| BTS |
160 |
| COAO |
24 |
| PDA + COAO |
23 |
| PDA + COAO + PA band |
7 |
| COAO + PA band |
7 |
| PDA + PA band |
6 |
| Blalock-Hanlon |
4 |
| PDA + BT shunt |
2 |
| PDA + COAO + arch repair |
1 |
| Other |
1 |
| Total |
418 |
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Selective use of CT in group II:
| BT shunt |
56 |
| PDA |
28 |
| COAO |
17 |
| PDA + COAO |
8 |
| PDA + PA band |
5 |
| PDA + PA band + COAO |
5 |
| PDA + Blalock–Hanlon |
2 |
| COAO + PA band |
2 |
| Blalock–Hanlon |
1 |
| Others |
4 |
| Total |
128 |
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Chest tube size for group II neonate was 12F. A few premature and tiny neonates (< 2.0 kg) received a 10F chest tube. All the other patients received larger CT. After surgery, 81 patients (19.4%) of group I had trivial pneumothorax (PTX) or fluid collection on initial postoperative CXR, which resolved in 24 hours or less. Twenty-six patients (6.2%) developed a PTX and 14 patients (3.3%) developed a fluid collection large enough to require insertion of a CT drainage. In this group, 29 CT and 11 thoracenteses were performed postoperatively.
Only one patient (0.2%) developed an undetected hemothorax with hypotension and needed reexploration with evacuation of the hemothorax and chest tube placement. He later became coagulopathic, developed another hemothorax undrained by the CT, and suffered neurologic sequelae.
In group II, 36 patients (28.1%) had a trivial persistent PTX or fluid collection postoperatively, five patients (3.9%) had a large PTX, and four patients (3.1%) had a large fluid collection not drained by the properly positioned chest tube. Three thoracenteses and eight new CTs were needed. One patient developed a PTX upon pulling out the CT, which spontaneously resolved.
No death in either group was related to the use or non-use of the CT. A total of 349 CT and collecting systems were saved.
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Comment
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Chest tubes are traditionally inserted during thoracic surgery to drain fluid and/or air. Their composition, size, position, and size of the patient influence their proper function [1–4]. Complication rates of CTs inserted in the operating room, mainly in the adult population, including empyema, unresolved PTX, persistent effusion, and incorrect placement, have been reported as high as 9.2% [5]. The drainage tube placed during surgery may become inefficient due to adhesions of the parietal and visceral pleura with resultant compartmentalization of the pleural space [6]. The suction many times applied to the CT attracts the pleura and diaphragm, thus obstructing the holes and making the drain ineffective. This is especially true in small patients who have softer and thinner structures, more easily attracted into the CT’s side holes [6]. Furthermore, small CTs may become obstructed early from clots and/or fibrin due to their small inner diameter, making additional tubes sometimes necessary to evacuate undrained air or fluid. Moreover, after insertion and lung expansion, the CTs can move to a "horizontal" position into the fissure and be ineffective [7]. In addition, the CT acts as a foreign body, as demonstrated by the increasing production of pleural fluid in the days following their insertion. The CT can also promote an excessive pleural reaction with fibrin accumulation, which may persist for up to 10 days [7] and in rare cases produce entrapment of the lung [8]. Less frequently reported complications are lung perforation [9, 10], esophageal perforation [11, 12], nerve damage (phrenic, long thoracic, stellate ganglion) [13–15], vascular lesions (pulmonary artery, subclavian artery) [16–18], cardiac tamponade/compression [19, 20], diaphragmatic perforation [6], and contralateral pleural perforation [21]. Finally, a new PTX, often small, was observed in 20.7% of the patients after removal of the CT, which did not resolved spontaneously in 5% of them [22]. We need to mention also the potential complications related to the collecting chambers, such as disconnection from the chest tube, cracks in their walls with secondary PTX, and lack of proper understanding from untrained health providers. Very little is written regarding this problem.
All of the above considerations prompt us to adopt a policy of selective use of CTs when closing thoracotomy incisions. In this setting, our rationale has always been that CTs are not justified as preventive but only as a therapeutic surgical tools. Therefore, in the absence of a visceral pleural tear or any substantial oozing, no CT is needed, since an air or fluid collection forming after surgery may or may not be drained by the compartmentalized chest tube, unless in the immediate vicinity. Likewise, there have been recent reports of video assisted thoracoscopic (VAT) surgery performed without CT insertion [23, 24].
The application of this selective use of chest tubes has been very rewarding since 90.5% of the patients in group I did well without chest tube insertion, 9.3% underwent an uneventful postoperative CT insertion or thoracentesis, and only one patient (0.2%) had complications. It is difficult to assume that this complication would have been avoided by the insertion of a chest tube at the time of the first surgery, since the patient, after evacuation of the retained hemothorax and chest tube insertion, later developed another accumulation of undetected and undrained bleeding.
It is not possible to determine the cost saving from this selective use, since many patients were operated on and transferred back to the neonatal or pediatric intensive care where their stay was dependent more on their original disease and clinical status than on the recovery from the surgical procedure.
We conclude that a selective approach to the use of chest tubes in thoracotomies for cardiovascular procedures can be employed with minimal and manageable risk, less discomfort for the patient, and with cost saving, if a protocol is strictly applied.
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Acknowledgments
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We are grateful to John M. Runnels and Jan S. Radakovich for assistance in editing this paper.
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Abstract
Introduction
