Ann Thorac Surg 2003;76:1046-1049
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy
Joseph Alex, MRCSa*,
Junaid Ansari, FRCSa,
Pradeep Bahalkar, MCha,
Sandeep Agarwala, FRCSa,
Mazhar Ur Rehman, FRCSa,
Ahmed Saleh, FRCAa,
Michael E. Cowen, FRCS (CTh)a
a Department of Cardiothoracic Surgery, Castle Hill Hospital, Kingston-Upon-Hull, United Kingdom
Accepted for publication April 18, 2003.
* Address reprint requests to Dr Alex, The Cottage, Main Rd, Covenham St. Bartholomew, Louth LN11 0PF, United Kingdom
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Abstract
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BACKGROUND: We compared the immediate postoperative outcome and cost-effectiveness of using a single chest drain in the midposition to the conventional apical and basal drains after lobectomy.
METHODS: Of the 120 consecutive patients who underwent thoracotomy and lobectomy for lung cancer at our center between January 2001 and December 2002, 60 had the conventional 28 French apical and basal drains (group A), whereas the remaining 60 had a single 28 French chest drain placed in the midposition before closure (group B). The assessed outcomes included length of stay, amount and duration of drainage, subcutaneous emphysema, postremoval hemothorax and pneumothorax, drain reinsertion, patient controlled analgesia duration, maximum pain scores, and analgesic usage.
RESULTS: Both groups matched in terms of age (group A vs group B mean, 65 years old vs 66 years old, respectively; p = not significant [NS]) and gender (M:F, 4:1 for group A vs 4:1 for group B). There was no significant difference in the length of stay (mean, 7.7 days for group A vs 7.8 days for group B; p = NS), amount of drainage (mean, 667 mL for group A vs 804 mL for group B; p = NS), duration of drainage (mean, 4 days for group A vs 4.3 days for group B; p = NS), duration of patient controlled analgesia (mean, 3.7 days for group A vs 4.2 days for group B; p = NS) and analgesic combinations used (nonsteroidal antiinflammatory drugs ± oral opioids ± paracetamol) between the two groups. There were no clinically significant postdrain removals of hemothorax or pneumothorax in either group. Group A patients had a significantly higher maximum pain score compared with group B patients (mean, 1.4 vs 1.02, respectively; p = 0.02). Cost savings per patient in group B was more than or equal to $55, which added up to a total cost savings of approximately more than or equal to $3,300.
CONCLUSIONS: A single chest drain in the midposition is just as effective, significantly less painful, and much more cost effective than the conventional use of two drains after lobectomy.
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Introduction
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The conventional method of pleural drainage after thoracotomy and lobectomy is the use of two chest drains placed in the apical and basal positions before closure. This method has been recommended by standard texts and has been accepted as the logical method of ensuring complete drainage of the pleura [1–3]. To date no studies have compared the efficacy, outcome, and costs saved by using a single chest drain as opposed to the conventional two-drain method.
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Patients and methods
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We compared the immediate postoperative outcome of 120 consecutive patients operated on between January 2001 and December 2002, anesthetized and operated on by the same consultant, anesthetist, and surgeon, respectively. The assessed variables and outcomes included, age, gender, length of stay, amount and duration of drainage, subcutaneous emphysema, postremoval hemothorax or pneumothorax, drain reinsertion rate, patient controlled analgesia (PCA) duration, maximum pain scores, analgesic usage and cost difference between the groups. All patients had lobectomy for T1/T2 –N0/N1 –M0 lung cancer with a standard posterolateral thoracotomy through the fifth intercostal space.
Group A (n = 60) patients had two similar 28 French drains (8888-561068; Sherwood medical, Gosport, UK), one in the apical and the other in the basal position (Fig 1),
whereas group B (n = 60) patients had a single 28 French chest drain sited in the midposition (Fig 2)
before closure. The drains were connected by tubing (R54502 [Rocket Medical Plc, Washington, England]) set to 1,800 mL single chamber chest drainage bottles (R54.502 [Rocket Medical Plc, Watford, England]), with each draining to separate bottles. All patients had an epidural catheter (100/391/118, 18G Minipack Epidural System 1, [SIMS Portex Ltd, Kent, UK]) sited at the T5 to T6 level before the operation and 1% lidocaine (Phoenix Pharma Ltd, Gloucester, UK) instilled locally into the thoracotomy wound and drain site at the end of the operation. The epidural solution was made up with one part fentanyl (50 µg/mL), one part plain Bupivacaine (0.5%), and three parts saline (0.9%), producing a final concentration of 10 µg/mL fentanyl and 1% bupivacaine. The PCA machine (Graseby 9000 series [Graseby Medical Ltd, Watford, UK]) was programmed to deliver a continuous background infusion (0.25 µg/kg/h), with a patient controlled bolus (1 mL with a lock-out time of 8 minutes). All patients were provided with an epidural PCA until drain removal or for the first 5 days if the drain was left in longer. In patients with prolonged chest drainage the epidural, PCA was substituted with an intravenous morphine PCA (50 to 100 µg/kg loading dose followed by PCA boluses of 1 mg with a lockout time of 5 minutes) until the drain was removed or until oral analgesia controlled the pain.
The oral analgesic combinations used for pain were nonsteroidal anti-inflammatory drugs ± opiods ± paracetamol. All patients were specifically shown and instructed on using the PCA machine by the admitting staff, which was later verified by the anesthetist before the operation. Postoperative pain was assessed and scored from 0 to 4 according to the hospital numeric verbal pain scale (Table 1)
by fully qualified senior ward nurses instructed in pain assessment. After surgery, pain assessment was carried out every 15 minutes for the first hour, hourly for the next 12 hours, and every 4 hours thereafter. During each assessment the volume of PCA solution used was noted to ascertain if the patients were using the calculated optimum dose. A pain score of 2 or above was deemed unacceptable and additional analgesia was then administered.
Those patients with chest drains were assessed for air leak and drainage every hour for the first 24 hours and then every 6 hours until removal. Suction of 20 cms of water was applied to the drains if the lungs were not fully expanded on chest roentgenogram and this was continued until full expansion was attained. In patients whose lungs were fully expanded, suction was not used even in the presence of an air leak. Each patient was clinically examined every morning and evening and the decision to remove drains were assessed if there was no air leakage on coughing, if fluid drainage was less than 100 mL in the previous 24 hours, and if chest roentgenogram confirmed the absence of a hemothorax or a pneumothorax. All patients had a postdrain removal chest roentgenogram.
Although there were no patients with lungs that failed to expand in either group, our policy in that type of situation would be to first apply as much as 20 cm of water suction to the drain, and in the absence of an air leak or if the air leak were to stop after 48 hours of suction and the residual pneumothorax was less than 10%, then the drain would be removed. If there was a persistent air leak with suction and a residual pneumothorax of less than 10%, and if pleurodesis was attempted and failed, then the drain would be connected to a Portex Ambulatory Chest Drainage system (200-905-000; SIMS Portex Ltd, Kent, UK) with an integral flutter valve. The patient would then be reviewed weekly, the drain would be connected to an underwater seal to assess for air leakage, and finally, the drain would be removed in the absence of air leakage. If despite these measures the pneumothorax were to remain greater than 10%, we would insert an additional chest drain.
The Windows SPSS program (version 11.0 [SPSS Inc, Chicago, IL]) was used for statistical analysis. Patient characteristics and results (Table 2
.) are displayed as mean ± standard deviation. The 
2 test and t test were used for categorical data and numerical data respectively, whereas the pain scores were analyzed using the nonparametric Mann-Whitney U test. Statistical significance was set at p less than 0.05.
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Results
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The mean age in group A was 65 + 8.4 years versus a mean age of 66 + 8.6 years in group B (p = not significant). The male to female ratio was 4:1 in both groups. In group A, 16 patients (26.7%) had right upper lobectomies, 13 (21.7%) had right middle lobectomies, 11 (18.3%) had right lower lobectomies, 12 (20%) had left upper lobectomies, and 8 (13.3%) had left lower lobectomies versus group B with 16 patients (26.7%) who had right upper lobectomies, 6 (10%) who had right middle lobectomies, 11(18.3%) who had right lower lobectomies, 16 (26.7%) who had left upper lobectomies, and 11(18.3%) who had left lower lobectomies (p = NS). All resection margins were confirmed to be disease free on histologic examination. There was no significant difference between the two groups (ie, group A vs group B) in terms of length of stay (7.7 ± 3 days vs 7.8 ± 3.2 days, respectively; p = NS), amount of drainage (mean, 667 + 369 mL vs 804 + 498 mL, respectively; p = NS), duration of drainage (mean, 4 + 3.2 days vs 4.3 + 3.3 days, respectively; p = NS), duration of PCA (mean, 3.7 + 1.5 days vs 4.2 + 1.7 days, respectively; p = NS), and analgesic combinations used (nonsteroidal anti-inflammatory drugs + oral opioids + paracetamol). After removal there was no incidence of clinically significant subcutaneous emphysema, pleural effusion, or pneumothorax necessitating drain reinsertion in either group. Group A (Fig 3)
patients had a significantly higher maximum pain score compared to group B (Fig 4
) patients (mean, maximum pain score, 1.4 + 0.8 vs 1.02 + 0.7, respectively) (p = 0.02).
The cost of one complete chest drain set used in our unit is more than or equal to $25. All patients in group A had at least one additional roentgenogram after removal of one of the drains. The radiology service cost for a digital roentgenogram is more than or equal to $23. The cost of other disposables, such as additional sutures, disposable stitch cutters, dressing pads, dressings, and drain removal packs are each more than or equal to $7. Thus the calculated minimum cost-saving per patient in group B was approximately more than or equal to $55, which amounted to a total cost-saving in group B of more than or equal to $3,300 compared with group A.
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Comment
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The standard and widely accepted practice in thoracic surgery has been to place apical and basal drains for complete drainage of the pleural cavity after lobectomy. This is based on the natural tendency of the fluid to gravitate to the bottom and displace air to the apex of the pleural cavity. However, the pleural cavity is not a fixed space; after lobectomy, expansion of the remaining lung, mediastinal shift, and elevation of the diaphragm would obliterate any space and squeeze out any residual fluid or air through an optimally placed drain. Further clearance occurs with changes in posture and to a much lesser extent though pleural resorption.
Pain control plays a major role in post-thoracotomy recovery and complications [4–7]. Optimizing pain control helps in early lung re-expansion through deep breathing exercises, better cough and expectoration of secretions, reducing the incidence of chest infections, and earlier mobilization. In this study a numeric verbal pain score greater than 2 was deemed unacceptable, and additional analgesia was administered. Almost all the maximum pain scores were recorded within the first 72 hours after surgery, and the number of drains used had a direct influence on the maximum pain scores. The main limitation of our study is the relatively small number of patients in each group. Again we did not compare the chest infection rates, antibiotic usage, and time to mobilization. In conclusion our study demonstrates that compared with the conventional two-drain method, a single chest drain in the midposition after lobectomy, drains fluid and air effectively, is significantly less painful, reduces the number of roentgenogram exposures, and can significantly reduce the cost of treatment. From the time this study was undertaken, we have continued to use a single chest drain after lobectomy for lung cancer and have maintained similar results to the study.
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References
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Abstract
Introduction
