Invited Commentary

Abstract

The current study by Cerfolio and Bryant [1Cerfolio R.J. Bryant A.S. Daily chest roentgenograms are unnecessary in nonhypoxic patients who have undergone pulmonary resection by thoracotomy.Ann Thorac Surg. 2011; 92: 440-444Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar] describes the impact of daily postoperative chest radiography in the management of 1,037 patients who underwent pulmonary resection during a 4-year period. The authors emphasize that all patients included in this study underwent thoracotomy. Patients who underwent pneumonectomy, video-assisted thoracoscopic procedures, or admission to the intensive care unit were excluded. The majority of the analysis was predicated on the presence of postoperative pneumothorax or hypoxia. The influence of other parameters such as fever, leukocytosis, arrhythmia, or bleeding is less clear. The authors observed that chest roentgenograms changed clinical management in 72% (49 of 62) of patients exhibiting hypoxia during their hospitalization, thus justifying the need for chest radiography. In contrast, only 27% (26 of 975) of patients required an alteration in clinical management in the absence of hypoxia. The authors conclude that daily chest roentgenograms provide little benefit in patients demonstrating no postoperative pneumothorax or in the absence of hypoxia during their hospitalization. One could argue that because a chest roentgenogram changed clinical management in nonhypoxic patients nearly one third (27%) of the time, daily chest radiography remains beneficial. There are occult findings on postoperative chest roentgenograms (lobar collapse, retained blood, alveolar infiltrates, small to moderate pneumothorax) that cannot always be detected clinically, and often precipitate alteration in clinical management. Moreover the adoption of video-assisted lobectomy in lung cancer care has led to fewer hospital days, thus already reducing the total number of postoperative chest roentgenograms. In an era of health care cost containment and increased awareness of cumulative radiation from diagnostic imaging modalities, the authors ask a valid question: Is it necessary to obtain daily chest roentgenograms in patients who experience routine pulmonary resection? There is little debate that chest radiography is overused in the postoperative management of routine pulmonary resection; however evidence-based recommendations are lacking. A redesign of clinical pathways for routine lobectomy, segmentectomy, or wedge resection will need to address this phenomenon. A simple prospective randomized controlled trial with some reasonable exclusion criteria can be constructed to understand the role of daily versus specifically indicated postoperative chest radiography in routine pulmonary resection. Daily Chest Roentgenograms Are Unnecessary in Nonhypoxic Patients Who Have Undergone Pulmonary Resection by ThoracotomyThe Annals of Thoracic SurgeryVol. 92Issue 2PreviewThe purpose of this study is to assess the clinical benefit of performing a daily chest roentgenogram (CXR) on patients who have had a pulmonary resection. Full-Text PDF