Chest Tube Days Research Articles

Outcomes of lung volume reduction surgery for emphysema: unilateral and bilateral.

Lung volume reduction surgery (LVRS) has historically been performed as a bilateral operation. We aimed to compare the short-term morbidity and mortality between unilateral and bilateral LVRS. We performed a retrospective analysis of patients who underwent LVRS for emphysema at two hospital sites over 10 years. Outcomes were compared between unilateral and bilateral LVRS by final approach. Functional outcomes included pulmonary functions tests (PFTs), 6-minute walk test (6MWT), and supplemental oxygen use. A total of 119 patients underwent LVRS. A unilateral approach was used in 64 (54%) patients, and the bilateral approach in 55 (46%). For the entire cohort, functional outcomes significantly improved post-LVRS. Bilateral LVRS showed non-significant improvement in residual volume (RV%) (-77.5 vs. -45, P=0.07) and forced expiratory volume in the first second (FEV1%) (+6.3% vs. +13%, P=0.07), and statistically significant improvement in diffusing capacity for carbon monoxide (DLCO%) (+2% vs. +9%, P=0.01), and 6MWT (-4 vs. +42.8, P=0.007) compared to the unilateral group. Procedure-related air leak (5 vs. 2.5, P=0.03) and chest tube days (7 vs. 4, P=0.01), and a longer hospital stay (8 vs. 5, P<0.001) were longer in the bilateral group compared to the unilateral group. Estimated survival at 1-year was 98.4% for unilateral and 90.9% for bilateral LVRS (P=0.09). Compared to unilateral LVRS, bilateral LVRS is associated with a greater functional improvement at the expense of short-term morbidity.

Robotic Lobectomy Learning Curve Has Better Clinical Outcomes than Videothoracoscopic Lobectomy.

Introduction: The robotic-assisted (RATS) lobectomy learning curve is usually measured compared to an established videothoracoscopic (VATS) surgery program. The objective of our study is to compare the learning curves of both techniques. Methods: We performed an intention-to-treat analysis comparing the RATS vs. VATS lobectomies. Surgical time, conversions, complications, number of lymph nodes (LNs) and lymph node stations harvested, chest drainage duration, length of stay, readmissions, and 90-day mortality were compared between both groups. The learning curve was assessed using the CUSUM method. Results: RATS cases (30) and VATS cases (35) displayed no significant differences. The RATS learning curve was completed after 23 procedures while the VATS curve required 28 interventions. Complications appeared in four RATS procedures and in eight VATS patients. No differences in the number of LNs and harvested LN stations were reported. Four patients were readmitted in the RATS group, and eight in the VATS group. No 90-day postoperative mortality was observed in either group. The RATS group reported fewer chest tube days (3 (2-5) vs. 5 (4-5.8), p = 0.005) and hospital days (4 (3-6) vs. 5 (4-6), p = 0.023). Conclusions: The RATS curve appears shorter than the VATS curve. RATS lobectomies resulted in reduced chest tube duration and length of stay during the learning time period.

Ameliorated chest drain wound closure in patients undergoing uniportal thoracoscopic pulmonary resection.

Although uniportal video-assisted thoracoscopic surgery (VATS) has been performed for a wide array of thoracic diseases, unsightliness and poor wound healing often occur, particularly when a chest drain is placed postoperatively. Different chest drain wound closure (CWC) methods have been introduced with the benefits of cosmesis and patient satisfaction. We aimed to describe our improved CWC technique in this setting and assess its efficacy. A total of consecutive 334 patients undergoing uniportal VATS pulmonary resection with single chest drain placement were investigated from 2016 to 2021. The techniques for CWC were classified into the conventional method (35 patients, group A), continuous suture with removal-free stitches (122 patients, group B), and continuous suture with removal-free barbed suture plus topical skin adhesives (177 patients, group C). Perioperative data and complications related to CWC were analyzed. Group C had a significantly shorter operative time, postoperative hospital stay, and chest tube days than groups A and B (all p < 0.01). In terms of chest tube-related complications, there were no statistically significant differences in post-removal pneumothorax, subcutaneous emphysema, incisional effusion leakage, wound dehiscence, or infection. Overall, significant differences in scar scale scores were observed between the groups, where the ameliorated group C was superior to the conventional group A (p < 0.01). The improved CWC technique using continuous sutures with removal-free barbed sutures and topical skin adhesives is simple, safe, and effective. This may be a favorable CWC strategy when performing uniportal VATS, with enhanced patient satisfaction.

Abstract 13267: Early Predictors of High-Risk Lymphatic Subtypes on T2-Weighted MRI in Patients After Superior Cavopulmonary Connection

Introduction: Lymphatic subtype as determined by T2-weighted MRI (T2-CMR) after superior cavopulmonary connection (SCPC) is known to predict clinical outcome after Fontan. Factors related to lymphatic subtype development are not well understood. This study aims to identify early predictors of high-risk lymphatic subtypes. Methods: Retrospective cohort study of consecutive patients with pre-Fontan T2-CMR from 2017 to 2021. Patients divided into two groups based on lymphatic subtype: Group 1 - subtypes 1, 2, and 3; Group 2 - subtypes 3+ (defined as type 3 with history of chylothorax) and 4. Pearson’s chi square, Fisher’s exact, Wilcoxon rank sum, univariate and multivariate logistic regression analysis were performed. Results: We identified 171 patients. The groups differed significantly in total hospital, ICU, and chest tube days, number of catheterizations and number of cardiac surgeries (Table 1). Moderate or greater atrioventricular valve regurgitation (Mod+ AVVR), increased catheterizations and increased chest tube days were associated with high-risk lymphatic subtype. Maintenance of antegrade pulmonary blood flow at the time of SCPC was not significant (Table 2). In multivariate analysis, Mod+ AVVR and number of chest tube days remained in the model after adjusting for other covariates. Overall model significance was 0.007 with an area under the curve of 0.777. Conclusions: Mod+ AVVR and increased chest tube days are predictive of high-risk lymphatic subtype. Further study is needed to determine if lymphatic subtype is acquired via clinical exposure or whether native lymphatic subtype may be predictive of clinical course even prior to cavopulmonary connection.

Diaphragmatic plication: current evidence and techniques in the management of the elevated hemidiaphragm

: Diaphragm plication is the preferred surgical intervention for elevation of the hemidiaphragm. This can be a consequence of trauma, damage to the phrenic nerve, or congenital eventration. There are numerous surgical approaches to diaphragmatic plication including open thoracic, open abdominal, minimally invasive transthoracic, minimally invasive transabdominal, and robotic assisted. All approaches are acceptable practices, but there has been a shift to more minimally invasive and video-assisted approaches. In this clinical practice review, we have assessed the current evidence and techniques used for hemidiaphragm elevation. Most evidence assessing the various techniques comes in the form of case studies, case series, and small institutional studies. Video-assisted thoracoscopic surgery is a commonly employed technique associated with positive outcomes as evidenced by improvement of pulmonary function test following the procedure, fewer chest tube days, decrease in self-reported dyspnea, and short hospital stays. Laparoscopic plication is also an acceptable technique. Multiple case studies showed overall positive outcomes with limited morbidity. Robotic assisted approaches were also reviewed. These interventions were shown to improve spirometry values and dyspnea scores. Minimal data exist on open abdominal approaches, and there are not currently enough data to assess their effectiveness. Open thoracic approaches were associated with improvements in spirometry as well as dyspnea scores. All surgical approaches discussed are acceptable strategies for the treatment of the elevated hemidiaphragm. No one intervention appears to be superior, but minimally invasive approaches have become more popular. The success of these procedures is largely believed to be based on surgeon preference and level of expertise.

Abstract 12034: Diffuse Myocardial Fibrosis, Its Distribution And Relationship To Clinical Outcome And Ventricular Function In Single Ventricles Before And After Fontan: A Cardiac Magnetic Resonance Outcome Study

Introduction: Patients with single ventricle (SV) anatomy are susceptible to myocardial fibrosis as measured by cardiac magnetic resonance (CMR) imaging. This study investigated the association of diffuse myocardial fibrosis prior to Fontan with ventricular function and clinical outcomes after Fontan completion. Methods: Retrospective cohort study of consecutive SV patients who underwent CMR T1 mapping prior to Fontan. Native T1 time and extracellular volume (ECV) of the dominant ventricle and a free wall region of interest (ROI) were measured on CMR pre-Fontan. Longitudinal strain was measured on echocardiography pre- and post-Fontan. Associations between pre-Fontan fibrosis, strain, and clinical outcomes were evaluated using linear and logistic regression. Results: 40 patients were included (table 1). ECV directly correlated to the number of ICU days and post-Fontan strain. The coefficient of variation (CV) of ECV directly correlated to hospital and chest tube days. When limited to single right ventricles (RV), T1 directly correlated to strain pre-Fontan. ECV directly correlated to ICU days as well as strain pre- and post-Fontan. ECV ROI directly correlated to strain post-Fontan. The CV of ECV directly correlated to the number of hospital days (table 2). Conclusions: Myocardial fibrosis prior to Fontan may portend the clinical course after Fontan and should be considered for risk stratification. The CV of ECV is a novel measure of diffuse fibrosis that is associated with clinical outcome. For single RV patients, fibrosis before Fontan is associated with worse ventricular function after. The use of reverse remodeling agents prior to Fontan should be considered.

Video-assisted thoracic surgery sleeve resection and bronchoplasty using 3D imaging system: its safety and efficacy

BackgroundVideo-assisted thoracic surgery sleeve resection with bronchial anastomosis or bronchoplasty is a technically demanding procedure. Three-dimensional endoscopic surgery has been reported to be helpful in decreasing operation time and improving spatial perception with less surgical errors, but there have been rare reports about relatively difficult thoracoscopic procedures utilizing 3D thoracoscope. We performed this study to evaluate early clinical outcomes of thoracoscopic sleeve resection and bronchoplasty utilizing 3D thoracoscope.MethodsData from a total of 36 patients who underwent thoracoscopic sleeve lobectomy or bronchoplasty at our institution from December 2015 to October 2017 were retrospectively reviewed. Three-port approach with one utility incision was used with a 10 mm, 30° three-dimensional thoracoscope. Twenty-three patients (81%) were male, and mean age was 65.9 ± 9.4 years. Fourteen patients (38.9%) underwent sleeve resection with bronchial anastomosis, 22 (61.1%) underwent wedge or simple bronchoplasty, and one patient received concomitant PA procedure. Bronchial anastomosis sites were not covered with viable tissue flaps.ResultsThere was no (0%) suture needle injury from spatial misperception during bronchoplasty or sleeve anastomosis. There was no (0%) operative mortality. The pathologic report revealed squamous cell carcinoma (63.9%), adenocarcinoma (19.4%), carcinoid (6.9%), adenosquamous carcinoma (3.4%), and sarcomatoid carcinoma (2.8%). One (2.8%) late mortality was due to systemic recurrence of sarcomatoid carcinoma. There was no (0.0%) anastomotic failure. The mean number of dissected lymph nodes were 27.4 ± 13.2, and mean operation time was 216.8 ± 60.0 min. Median postoperative 24-h drain amount was 315 mL. Median chest tube days and hospital days were 4 and 6, respectively. Two patients (5.6%) had complications greater than Clavien-Dindo grade II—one case of ARDS, and the other case of a delayed bronchopleural fistula.ConclusionsThoracoscopic sleeve resection and bronchoplasty utilizing HD 3D thoracoscope is a safe and effective procedure with excellent early clinical outcomes. Further investigation for long-term outcomes will be needed.

Examining the impact of physical function performance in predicting patient outcomes after lung-sparing surgery for malignant pleural mesothelioma

ABSRACT Purpose The purpose of this study was to examine the impact of physical function performance and pulmonary function on patient outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM). Materials and methods A retrospective review of 54 patients with MPM from 2015 to 2020 was performed. The primary objective was to assess whether physical function, as measured by the Eastern Cooperative Oncology Group Performance Status (ECOG), and pulmonary function tests were predictive of postoperative patient outcomes (ventilator days, chest tube days, hospital length of stay). A secondary objective was to explore demographic and preoperative variables that best predict postoperative physical function and patient outcomes. Results Data include 54 patients who underwent extended pleurectomy-decortication. Preoperative ECOG was a significant predictor of postoperative patient outcomes while preoperative lung function lacked predictive ability. Preoperative ECOG was also predictive of preoperative lung function. Age on the day of surgery was the best predictor of postoperative physical function, which was significantly reduced postoperatively. Conclusions Preoperative physical function performance was a significant predictor of postoperative outcomes. The results of our study highlight the importance of physical function in patients with MPM and support the need for early rehabilitation and further research to determine optimal rehabilitation interventions. IMPLICATIONS FOR REHABILITATION Preoperative physical function can predict outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM). Physical function in patients with MPM should be carefully examined. To accurately reflect patients’ abilities, patient assessment should include both patient-reported outcomes and performance-based measures. Patients with MPM should receive rehabilitation early after diagnosis and throughout the continuum of care.

Robotic Surgery and Anatomic Segmentectomy: An Analysis of Trends, Patient Selection, and Outcomes

BackgroundWhether robotic segmentectomies are advantageous is unclear. We describe our experience with the robot, comparing patient populations and outcomes with video-assisted thoracoscopic surgery (VATS) and open resection. MethodsPatients who underwent anatomic segmentectomy from 2004 to 2019 were reviewed. Resection methods were categorized as robotic, VATS, or open. Segmentectomies were categorized as simple or complex. Baseline characteristics and perioperative outcomes were analyzed from 2015 to 2019 due to implementation of the Enhanced Recovery After Surgery pathway for all thoracic surgery patients and to thus minimize confounders resulting from the Enhanced Recovery After Surgery protocol. ResultsSince 2004, an increase has occurred in segmentectomies, including robotic and complex segmentectomies. Of the 222 segmentectomies performed from 2015 to 2019, 77 (35%) were robotic, 40 VATS (18%), and 105 open (47%). More complex segmentectomies were performed in the robotic group compared with VATS and open (45% vs 15% vs 22%; P < .001). Operative time for robotic resections were longer compared with VATS and open (205 vs 147 vs 147 minutes; P < .001) but had lower blood loss (50 vs 75 vs 100 mL; P < .001) and shorter chest tube days (2 vs 2 vs 3 days; P = .004) and lengths of stay (3 vs 3 vs 4 days; P < .001). Perioperative mortality was low in all groups. No robotic segmentectomy was converted to open compared with 7.5% for VATS (P = .038). Prolonged air leak was lower for robotic compared with open (4% vs 13%; P = .038). ConclusionsRobotic segmentectomy has increased in our institution, with a concurrent rise in atypical segmentectomies. Despite performing more complex procedures, there were no conversions and low perioperative morbidity and mortality. Our results suggest that the robotic platform can facilitate performance of complex anatomic segmentectomies.

The benefits of digital drainage system versus traditional drainage system after robotic-assisted pulmonary lobectomy.

Postoperative air leaks are the most common complication after a pulmonary resection. There is no data in the literature comparing the traditional and digital chest drainage system after a robotic-assisted pulmonary lobectomy. This was a retrospective, correlational study. Medical records from 182 eligible robotic-assisted lobectomy patients were evaluated to determine the association between digital and traditional chest tube drainage systems (CTDS) with postoperative chest tube days, hospital LOS, chest tube reinsertion during hospitalization, and 30-day readmission for pneumothorax. Multiple regression was used to determine the association between CTDS while controlling for confounding variables. No differences were noted between groups for age, gender, BMI, smoking, adhesions or neoadjuvant therapy. Patients with digital drainage systems had significantly shorter chest tube duration than those with traditional drainage systems (2.07 vs. 2.73 days, P=0.003). After controlling for age and BMI, CTDS was not found to be a significant predictor of CT duration. Digital drainage system were also associated with significantly shorter hospital LOS (4.02 vs. 5.06 days, P=0.01) After controlling for age, BMI, and presence of post-op a-fib, use of a digital CTDS was significantly associated with 1 day shorter hospital LOS. Chest tube reinsertion occurred four times more frequently with traditional drainage systems, but the difference did not achieve the level of statistical significance (P=0.059). The frequency of readmission due to pneumothorax was very low (1 patient per group), which prevented comparative statistical analysis. In the digital drainage system there are shorter chest tube days and hospital length of stay after a robotic-assisted lobectomy. The decision to remove chest tubes in the traditional drainage system is burdened with uncertainty. The digital drainage system reduces intraobserver variability allowing for improved decision making in chest tube removal. Both CT duration and hospital LOS were shorter using unadjusted analyses. Type of CTDS was not significantly associated with CT duration after controlling for age and BMI. However, after controlling for age, BMI, and post-op atrial fibrillation, use of the digital CTDS was associated with a 1 day reduction in hospital LOS.

Risk Factors That Increase Nosocomial Infections among Patients with Chest Tube

Background: chest drains are used for patients who have undergone cardiothoracic surgery or chest trauma. It maintains cardiorespiratory function and hemodynamic stability by draining the pleural and mediastinal spaces of air, blood or other fluids. The aim of the study was to identify the risk factors that increase nosocomial infections among patients with a chest tube. A descriptive research design was used to conduct this study. The sample was consisted of a convenience sixty adult patients with a chest tube. The following tools were utilized for data collection: Patient' Assessment Sheet, Chest Tube' Assessment Sheet and Risk Factors of Nosocomial Infections' Assessment Sheet. Results concluded that; there was statistically significant difference between risk factors of nosocomial infection, the reason of insertion, type, place, site, number, the frequency of dressing and chest tube days. Conclusion: the most common risk factors were contaminated respiratory therapy equipment, mechanical ventilation, blood transfusion, mixed antibiotics, chronic illness, understaffing, overcrowding, improper hand washing and use of invasive devices. Recommendations: swabs should be taken from the site regularly and use aseptic technique when caring for patients to detect and prevent further infection.

Air Leak Management Program With Digital Drainage Reduces Length of Stay After Lobectomy

Air leaks can impede recovery from lung resection. To help prevent and manage air leaks, we developed a comprehensive program that includes using precompression of lung staple lines, sealant, fissureless video-assisted thoracoscopic (VATS) lobectomy, a digital drainage system, and endobronchial valve placement for prolonged air leak. We assessed the effectiveness of this program on air leak duration, hospital length of stay (LOS), and chest tube duration in our high-risk veteran population. Using a prospectively maintained database, we retrospectively analyzed data from 226 patients whounderwent lung resection for cancer by VATS lobectomy in a Veterans Affairs center. Patients were divided into two groups. Group A (n= 134; historical controls) underwent lobectomy from July 2009 through October 2013; group B (n= 92; intervention group) underwent lobectomy from November 2013 through July 2016 and received care per the comprehensive program. The median hospital LOS was significantly shorter in group B than in group A patients (5 days versus6 days, respectively; p= 0.0001). Group B had a shorter median chest tube duration (2 days versus 3 days, p= 0.027). Prolonged air leak (more than 5 days) occurred in 5.4% of group B and 9.7% of group A patients (p=0.24). Prolonged LOS (more than 14 days) was less frequent in group B (1.1%) than in group A (8.2%, p=0.030). Multivariable analysis showed that predictors of decreased air leak duration, chest tube duration, and LOS included undergoing surgery in the later period (group B). Our comprehensive program was associated with reduced chest tube days and hospital LOS.

Chest Wall Stabilization Leads to Shortened Chest Tube Stay Time in Rib Fracture Patients after Traumatic Chest Wall Injury

Rib fixation has become a strategy for patients with displaced rib fractures and hemo/pneumothoraces (HTX/PTX). Rib plating improves pain control and respiratory mechanics, thereby reducing recovery times and morbidity/mortality. Current treatment consists of chest tube placement, pain control, and pulmonary toilet. The addition of rib plating should reduce time till HTX/PTX resolution and chest tube removal. The study compares chest tube stay time in rib-plated patients with those managed with current treatment. We hypothesize that patients undergoing rib plating will have a reduction in chest tube stay times. A retrospective review of a Level 1 trauma registry was performed. Rib-plated patients (n = 70) from 2013 to 2015 were compared with a randomly selected, nonoperative, injury-matched, historical (2003-2008) control group (n = 60). Demographics were obtained. Independent variables analyzed include Injury Severity Score (ISS), intensive care unit days, length of stay, and chest tube stay times. 60 control patients had an average ISS of 19 and age of 51 years, compared with ISS of 20 and age of 56 years in plated patients. Plated patients had a reduction in chest tube days, 6.5 versus 8.4 days, P value = 0.02. Plated patients had 14 intensive care unit days versus 19 days, P value = 0.09. T tests were performed to confirm significance. Reduction in chest tube days improves patient pain and allows for improved ambulation and pulmonary toilet, helping reduce respiratory complications. Our review shows that plating may prove beneficial in reducing complications associated with management of HTX/PTX in the setting of rib fractures.

Chest drainage systems and management of air leaks after a pulmonary resection.

Air leaks after a pulmonary resection continue to be the most common postoperative complication. The presence of an air leak occurs in approximately 30-50% of patients immediately after surgery. Prolonged air leaks (PALs) predict an increased hospital length of stay, additional chest tube days and increased pain. The two types of systems used after surgery are digital and traditional chest drainage devices. Eighteen articles from four databases were evaluated for this analysis in chest drainage systems and managing air leaks after thoracic surgery. The digital and traditional drainage devices were evaluated. PALs were examined with interobserver variability of air leak assessment and differences in the two systems were addressed. The research gaps in the digital system are examining what flow thresholds should be used to safely remove a chest tube after surgery and for what length of time. In future research, the next step is standardizing chest tube management to decrease individual surgeon preference. Treatment of air leaks implementing scientific data instead of personal preference and opinion by a surgeon can lead to earlier chest tube removal, decreased morbidity and a shorter hospital stay.

Statistical methodology for estimating the mean difference in a meta‐analysis without study‐specific variance information

Statistical inference for analyzing the results from several independent studies on the same quantity of interest has been investigated frequently in recent decades. Typically, any meta-analytic inference requires that the quantity of interest is available from each study together with an estimate of its variability. The current work is motivated by a meta-analysis on comparing two treatments (thoracoscopic and open) of congenital lung malformations in young children. Quantities of interest include continuous end-points such as length of operation or number of chest tube days. As studies only report mean values (and no standard errors or confidence intervals), the question arises how meta-analytic inference can be developed. We suggest two methods to estimate study-specific variances in such a meta-analysis, where only sample means and sample sizes are available in the treatment arms. A general likelihood ratio test is derived for testing equality of variances in two groups. By means of simulation studies, the bias and estimated standard error of the overall mean difference from both methodologies are evaluated and compared with two existing approaches: complete study analysis only and partial variance information. The performance of the test is evaluated in terms of type I error. Additionally, we illustrate these methods in the meta-analysis on comparing thoracoscopic and open surgery for congenital lung malformations and in a meta-analysis on the change in renal function after kidney donation. Copyright © 2017 John Wiley & Sons, Ltd.

Application of external suction combined with multiaperture catheter after lung bullae resection

Objective We applied external suction to carry out lung expansion after lung bullae resection, and evaluate the clinical value. Methods 122 patients undergoing video-assisted thoracoscopic pulmonary bullae resection were randomized into group A (n=65) and group B (n=57). In group A, we used negative pressure suction to carry out lung expansion, while manual hyperinflation was used in group B. The development of pulmonary atelectasis, reexpansion pulmonary edema and non-surgical side pneumothorax were recorded, and the chest tube drainage duration was recorded finally. Results The development of pulmonary atelectasis, reexpansion pulmonary edema and non-surgical side pneumothorax between the two groups had no statistically significant difference (P>0.05). In 58 patients (58/65) chest tube was removed within 7 days in group A, and 48 patients (48/57) in group B. For these patients, the mean duration of chest tube (days) was shorter in group A [(3.71±1.20) days] than in group B [(4.58±1.27) days] (P 0.05). Conclusion External suction combined with multiaperture catheter is safe and effective for lung expansion after lung bullae resection. This treatment shortens the duration of chest tube placement, but it can not reduce the incidence of postoperative complications. Key words: Pulmonary bullae; Negative pressure suction; Manual lung expansion; Complication

Early extubation in pediatric heart surgery across a spectrum of case complexity: Impact on hospital length of stay and chest tube days

Early extubation is increasingly common in congenital heart surgery, but there are limited outcomes data across the spectrum of case complexity. We performed a retrospective review of 201 pediatric operations using cardiopulmonary bypass between 2012 and 2014. Patients extubated in the operating room or immediately on arrival to the ICU were compared to those extubated by traditional protocols. In-hospital mortality, major complications, need for re-intubation, hospital length of stay, and chest-tube days were compared between groups and by Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery (STAT) mortality category. Outcome measures of hospital length of stay and chest tube days were analyzed using multivariable regression modeling. Early extubation subjects were older, weighed more, had shorter bypass and aortic cross-clamp time, more often received caudal anesthesia, and had shorter hospital length of stay and fewer chest tube days. Subjects not extubated early had more chromosomal abnormalities, more preoperative co-morbidities, and had more major complications. Inhospital death, major complications, and re-intubation were rare outcomes for both groups across all STAT categories. Multivariable regression analysis showed that cardiopulmonary bypass time was a significant predictor of hospital length of stay and chest tube days. Hospital LOS and chest tube days were significantly lower for the early extubation group in both the unadjusted and adjusted analyses. Early extubation can be performed safely in congenital heart surgery across a spectrum of case complexity. No increased early mortality or re-intubation was observed with early extubation although there were important differences between the groups that merits further study. The potential benefits of early extubation include decreased hospital length of stay and fewer chest tube days, particularly in young children and patients with long bypass times.

Sublobectomy versus lobectomy for stage I non-small cell lung cancer in the elderly

ObjectiveThe aim of our study was to compare the operative characteristics and long term survival for elderly patients with stage I non-small cell lung cancer (NSCLC) who underwent sublobectomy versus lobectomy. MethodsWe identified 245 consecutive elderly patients (≥65y) with pathologic stage I NSCLC who underwent lobectomy or sublobectomy at our institution between 2006 and 2012, and assessed the operative characteristics, recurrence, and survival differences between these approaches. ResultsA total of 39 patients underwent sublobectomy and 206 patients had lobectomy. There were significantly more COPD (p = 0.046) and low percent of predicted FEV1 (p = 0.034) in sublobectomy patients compared to the lobectomy group. Sublobectomy patients had significantly shorter operating time (p = 0.001), less blood loss (p = 0.000), and trended toward fewer chest tube days (p = 0.001) and shorter hospital length of stay (p = 0.030). The 1-, 3-, and 5-year survival rates in patients with lobectomy were 91.3, 77.7, and 64.1%, respectively, and has no significantly difference with those underwent sublobectomy (87.2, 74.4, and 61.5%, respectively, p = 0.623). Subgroups survival analysis showed no significant difference in the OS and DFS for patients with T < 2 cm or %FEV1<80%, but survival after sublobectomy was worse if performed on patients with larger tumours (T ≥ 2 cm) or relatively strong lung function (%FEV1≥80%). ConclusionWe concluded that sublobectomy might achieve similar survival rates when compared with lobectomy in elderly stage I NSCLC patients, especially for patients with low %FEV1 and stage IA tumours less than 2 cm in diameter.

Does thoracoscopy have advantages over open surgery for asymptomatic congenital lung malformations? An analysis of 1626 resections

AimThe apparent incidence of antenatally diagnosed congenital lung malformations (CLM) is rising (1 in 3000), and the majority undergo elective resection even if asymptomatic. Thoracoscopy has been popularized, but early series report high conversion rates and significant complications. We aimed to perform systematic review/meta-analysis of outcomes of thoracoscopic vs open excision of asymptomatic CLMs. MethodsA systematic review according to PRISMA guidelines was performed. Data were extracted for all relevant studies (2004–2015) and Rangel quality scores calculated. Analysis was on ‘intention to treat’ basis for thoracoscopy and asymptomatic lung lesions. Meta-analysis was performed using the addon package METAN of the statistical package STATA14™; p<0.05 was considered significant. Results36 studies were eligible, describing 1626 CLM resections (904 thoracoscopic, 722 open). There were no randomized controlled trials. Median quality score was 14/45 (IQR 6.5) ‘poor’. 92/904 (10%) thoracoscopic procedures were converted to open. No deaths were reported. Meta-analysis showed that regarding thoracoscopic procedures, the total number of complications was significantly less (OR 0.63, 95% CI 0.43, 0.92; p<0.02, 12 eligible series, 912 patients, 404 thoracoscopic). Length of stay was 1.4days shorter (95%CI 2.40, 0.37;p<0.01). Length of operation was 37 min longer (95% CI 18.96, 54.99; p<0.01). Age, weight, and number of chest tube days were similar. There was heterogeneity (I2 30%, p=0.15) and no publication bias seen. ConclusionsA reduced total complication rate favors thoracoscopic excision over thoracotomy for asymptomatic antenatally diagnosed CLMs. Although operative time was longer, and open conversion may be anticipated in 1/10, the overall length of hospital stay was reduced by more than 1day. Level of evidence4 (based on lowest level of article analyzed in meta-analysis/systematic review).

Digital Drainage System Reduces Hospitalization After Video-Assisted Thoracoscopic Surgery Lung Resection

The purpose of this study was to assess the efficacy of a digital versus traditional drainage system on hospitalization for patients undergoing video-assisted thoracoscopic surgery (VATS) anatomic lung resection. Consecutive patients who underwent VATS anatomic lung resection (July 2014 through January 2015) for lung cancer were analyzed. Patients were managed with overnight suction (-20 cm H2O) followed by gravity drainage (water seal or-8 cm H2O) in both the traditional and digital drainage systems, respectively; the digital system also allowed for continuous monitoring of air leaks. Chest tubes were removed when the air leak was absent for 12 hours and pleural drainage was less than 300 mL/24 h; patient outcomes selected by propensity matching were compared. The VATS lung resections (lobectomy or segmentectomy) were performed in 108 patients during the 7-month study period. The pleural cavity was drained with the traditional system in 75 patients and with the digital system in 33 patients. By propensity score matching at a 2:1 ratio, 40 patients were placed in the traditional group and20 patients, in the digital group for analysis. Demographics, percent predicted forced expiratory volume in 1 second, tumor size, stage, and type of resection were similar between the groups. The majority of patients (85%) underwent a lobectomy. There were no operative deaths. Overall complications were fewer in the digital system group (22%) compared with the traditional system group (35%; p= 0.01). Median air leak days (-1.1), chest tube days (-1.6), and total hospital stay (-1.5) were significantly reduced in the digital drainage system group. Patients undergoing VATS lung resections who were managed postoperatively with a digital drainage system experienced less morbidity and decreased hospitalization. A digital drainage system appears to be a safe alternative for management of the pleural cavity after VATS anatomic lung resection.