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Ann Thorac Surg 2006;81:331-333
© 2006 The Society of Thoracic Surgeons

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New technology

The Use of Flexible Silastic Drains After Chest Surgery: Novel Thoracic Drainage

Department of Chest Surgery, Tokushima Red Cross Hospital, Komatsushima City, Tokushima, Japan

Accepted for publication May 24, 2005.

^_* Address correspondence to Dr Ishikura, Department of Chest Surgery, Tokushima Red Cross Hospital, Komatsushima City, Tokushima, 773-8502 Japan (Email: sashi2000{at}mac.com).

	Abstract

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PURPOSE: We report a new strategy for drainage with silicon thoracic tube (Blake drain) after chest surgery.

DESCRIPTION: To confirm the effect of Blake drain, we have performed a three-part study including in vitro and clinical investigations compared with those of conventional chest tubes. We carried out an in vitro analysis to achieve the best possible drainage; in the second part, we used this drain in a cohort of 30 patients to establish safety and efficacy; and in a third substudy, we carried out a nonrandomized comparison with an earlier cohort between the Blake drain group and standard, rigid drain group.

EVALUATION: In vitro tests demonstrate that the drainage capability of the Blake drain depends on sufficient length in the fluted part of the structure. Clinical outcome demonstrates no significant differences. The Silastic drain (Ethicon, Inc, Somerville, NJ) group had a significantly shorter period of tube drainage compared with the conventional drain group.

CONCLUSIONS: From this small study the Blake drains seem to be safe and effective. Therefore, a prospective, randomized comparison should be carried out.

	Introduction

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In many institutions, drainage of the pleural space after respiratory surgery is routinely achieved with rigid, large-bore plastic drains (24-French to 36-French). Although these drains are effective, they are painful for the patients, particularly during removal. In addition, because of their size and rigidity, such chest tubes hinder postoperative recovery by limiting ambulation and deep breathing.

Recent preliminary reports suggest that small Silastic drains (Ethicon, Inc, Somerville, NJ) may be superior to the conventional chest tube in terms of patient tolerability and earliness of ambulation, as well as applicability in cardiac surgery with no disadvantages compared with the rigid chest drain [1, 2]. The Blake Silastic drain (Ethicon, Inc) is a 19-French round drain with grooves that run along the length of the tube. The fluted design is believed to promote fluid drainage and may cause less pain because of its small size and flexibility, because there is no data proving these claims to be true.

There have been no reports to date on the use of the Silastic drain (Ethicon, Inc) for drainage after general thoracic surgery. To confirm the effect of the Blake drain, we have performed a three-part study including in vitro and clinical investigations compared with those of conventional chest tubes. We report here a new strategy for drainage after chest surgery.

	Technology and Technique

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In the first study, the creators of the Blake drain designed it with special features for the purpose of minimizing tube obstruction. To determine the drainage capability of the fluted silicone drain (ie, size 19-French), we carried out a study under two different sets of experimental conditions. In the first case, the test was performed with three different types of Blake drains: (1) a regular 19-French drain (B-1) (Fig 1); (2) a drain with the fluted section shortened by approximately 10 cm (B-2); and (3) a drain with the fluted section cut off and with several side holes (B-3). The fluted section of the drain was placed in a chunk of chicken breast with approximately the top 10 cm of drain (B-1) exposed from the chicken breast. The drain was connected to a J-VAC suction reservoir with a 300-mL capacity. In the second case, a drain with only the fluted section was placed in two connected plastic bags to evaluate whether liquid and air were vacuumed through the entire fluted section or not. Then 180 cc colored water was put in each plastic bag, and the silicone drain was connected with a J-VAC suction reservoir with a 300-mL capacity.

View larger version (70K): [in this window] [in a new window]   Fig 1. The fluted section of the silicone Blake drain.

In the second study the patients with a diagnosis of lung cancer (including suspected cases) and pneumothorax were eligible for this trial. Subjects included 30 consecutive patients scheduled for routine chest surgery (ie, 11 for lobectomy, 2 for pneumonectomy, 7 for wedge resection of the lung, and 10 for pneumothorax). After the appropriate surgical procedure, a 0.5-cm incision was made in the intercostal space in the anterior axillary line behind the pectoralis major muscle (Fig 2). The Blake drain was inserted by blunt dissection and was placed so that it would be airtight. We insert Blake drains in the thoracic cavity initially in the direction of the apex and posterior, then looping so that the tip reaches down to the diaphragm (Fig 3). The Silastic drain (Ethicon, Inc) was connected to a three-chambered disposable plastic unit with a negative pressure of 5 cm H₂O or with a water seal. When no air leak and drainage of less than 200 mL per day were confirmed, the drain was then removed. Some authors have suggested that tubes should be removed at the end of expiration, some at the end of inspiration or with a Valsalva maneuver. However, when a Blake drain is removed, the patient simply pauses breathing at any breath position. There is no need to suture or staple the wound after removal of the tube, because the wound was small and muscles are preserved. In the present study, we examined a set of complications (ie, mortality, reoperation due to bleeding, need for another drain due to air leak, and so forth) to compare the Blake drain with rigid drains.

View larger version (137K): [in this window] [in a new window]   Fig 2. Blake drain inserted at the upper anterior axillary line.

View larger version (86K): [in this window] [in a new window]   Fig 3. (A) This chest roentgenogram shows the Blake drainage tube inserted so that it points to the apex and to the posterior, as well as downward. (B) Arrows indicate the drain in the thoracic cavity on a lateral view.

In the third study, in order to compare the clinical outcome of patients with a large, rigid tube with that of patients with a Blake drain using specific quantitative parameters, we investigated 18 recent consecutive patients with primary lung cancer (13 of whom were included in the initial study group) who underwent lobectomy or pneumonectomy with lymph node dissection and received a 19-French Blake drain and 15 lung cancer patients who received a 24-French rigid plastic drain during the last year. The Silastic drains (Ethicon, Inc) were found to produce a similar average output with that of the conventional chest tubes (data not shown). Blake drains were left in for an average of 2.4 days (median, 2 days; range, 1 to 4 days), which was significantly shorter than conventional drains (average, 4.5 days; median, 4 days; range, 2 to 11 days; p < 0.01 by the Mann-Whitney U test). There were no significant differences between the two groups with respect to postoperative length of stay; the mean postoperative length of stay was 9.1 days (median, 9 days; range, 3 to 21days) in the Silastic group (Ethicon, Inc) and 10.5 days (median, 10 days; range, 6 to 15 days) in the conventional group (p = 0.121).

	Comment

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Pain and discomfort associated with the presence of a chest drain and with its removal hinder early ambulation and discharge of surgical patients. In the present study, we used a small flexible drain to limit postoperative pain and encourage earlier ambulation. In the first part, we carried out an in vitro analysis to determine the key components of the Blake drain in order to guide us in how to precisely utilize it to achieve the best possible drainage after pulmonary resection; in the second part, we used the drain in this fashion in a cohort of 30 patients to establish safety and efficacy; and in a third substudy, we carry out a nonrandomized comparison of a group of patients in whom the Blake drain was used to an earlier cohort in whom a standard, 24-French rigid drain was used.

Blake silicone drains are small-bore (19-French), round, flexible fluted drains that exert constant suction over the entire length of the fluted portion of the drain. The presence of recessed channels along the side allows for greater tissue contact area and diminishes tissue intrusion into the drain. This provides more efficient drainage while minimizing tissue trauma and pain on drain removal. In addition, Akowuah and colleagues [3] report that flexible fluted silicone drains do not lead to an increase in pleural or pericardial effusions, or reexploration for tamponade, or bleeding after cardiac surgery.

By our own observations, the Blake drains are much more comfortable while in place and are less painful to remove than the larger rigid tubes that have been used in the past, and we found no significant differences in outcome between patients with a Blake drain and those with a conventional drain according to the clinical pathway. It has been our impression that pain is less in patients with the Blake drain, but we did not quantitatively evaluate pain. This would be one appropriate endpoint for a randomized comparison of Blake drains versus standard drains.

The period of tube drainage in the Silastic drain (Ethicon, Inc) group was found to be statistically, significantly shorter than that in the conventional drain group, and the postoperative length of stay also tended to be shorter in the Blake drain group. Although we cannot attribute these shorter times to the chest tube alone, it is certainly true that pain during tube drainage may prevent early ambulation.

As a result of this trial, there was a shift in our clinical practice toward exclusive use of Silastic drains (Ethicon, Inc) after all thoracic surgical procedures. From this small study, the Blake drains seems to be safe and effective, and therefore a prospective, randomized comparison should be carried out.

	Disclosures and Freedom of Investigation

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The authors have no commercial associations or sources of support that may pose a conflict of interest. Also, the authors had full control of the design of the study, methods used, outcome measurements, analysis of data, and production of this article.

	Disclaimer

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The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.

	References

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1. Frankel TL, Hill PC, Stamou SC, et al. Silastic drains vs conventional chest tubes after coronary artery bypass Chest 2003;124:108-113.[Abstract/Free Full Text]
2. Lancey RA, Gaca C, Vander Salm TJ. The use of smaller, more flexible chest drains following open heart surgery Chest 2001;119:19-24.[Abstract/Free Full Text]
3. Akowuah E, Ho EC, George R, et al. Less pain with flexible fluted silicone chest drains than with conventional rigid chest tubes after cardiac surgery J Thorac Cardiovasc Surg 2002;124:1027-1028.[Free Full Text]

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