Ann Thorac Surg 2006;81:334
© 2006 The Society of Thoracic Surgeons
New technology
Invited commentary
Joseph B. Shrager, MD
Department of Surgery University of Pennsylvania School of Medicine 4th Floor Silverstein 3400 Spruce St Philadelphia, PA 19104-4283
(Email: joseph.shrager{at}uphs.upenn.edu; jshrag{at}mail.med.upenn.edu).
Although this contribution by Ishikura and Kimura [1] has significant shortcomings with regard to the careful description of both experimental procedures and results, I believe the results are credible and that those results that are clearly interpretable are of considerable importance. The value of this article lies in the fact that it is the first to describe a series of pulmonary resections in which commercially available, soft, silastic thoracic drains are used for postoperative drainage rather than standard, more rigid thoracostomy tubes. These silastic drains have been studied in a randomized fashion in cardiac surgery with apparently equivalent drainage results and less pain than traditional tubes, but I believe they have not been systematically applied or studied in general thoracic surgery.
This article provides a modest amount of preliminary data that may serve as the starting point from which to accumulate additional information regarding the safety and efficacy of these drains. I believe that this small study goes a long way toward establishing safety; sufficient data is presented to allow one to conduct a future randomized trial with equipoise, but the trial design here and the numbers of patients involved certainly do not allow any conclusions to be drawn about efficacy.
A few of the areas in which this presentation has flaws and major questions remain include the following: the authors' emphasis on reduced pain with the use of these drains is misguided as they present no objective pain measurements, and it is by no means evident that a 19-French standard drain would be either more painful or a less efficient form of drainage than a 19-French silastic drain. For similar reasons, the claims regarding improved cosmesis seem somewhat farfetched. Although the authors write that, "The presence of recessed channels ... diminishes tissue intrusion into the drain," they provide no evidence that this is the case. In fact, the in vitro portion of the study is very difficult to decipher, and therefore it is hard to know what conclusions can be drawn from it. In the clinical portions of the study, we are not told at what level the negative pressure was kept in the traditional drain group, or for how long, and we are not told whether the management of these important aspects of chest drainage were standardized between the groups. Furthermore, although the authors state that " ... there were no difficulties of drain control," it seems unlikely from the article that residual effusion either in-hospital after drain removal or at late postoperative follow-up was quantified or even evaluated.
To summarize, this article, despite its substantial flaws, may represent the first step toward a change in our practice of chest drainage after pulmonary resection. I believe that the data presented allows us to proceed with equipoise toward a carefully performed randomized trial of these drains versus the traditional chest drains. If silastic drains are in fact proven to be equally effective and less painful than standard, rigid thoracostomy tubes, and if they can be offered at a reasonable cost, then they may become more widely used in the future.
 |
References
|
|---|
- Ishikura H, Kimura S. The use of flexible silastic drains after chest surgery: novel thoracic drainage Ann Thorac Surg 2006;81:331-334.[Abstract/Free Full Text]
Top
References