Duration Of Pleural Drainage Research Articles

Factors Influencing Pleural Effusion after Fontan Operation: an Analysis with 95 Patients

To investigate the association between preoperative, operative, and postoperative factors and persistent pleural effusion after the extracardiac Fontan procedure. Ninety-five consecutive patients diagnosed with univentricular heart underwent extracardiac connection using Gore-Tax conduits at the Department of Children's Heart Centre, Justus-Liebig-University Giessen in Germany from June 1996 to July 2007. The outcome measures were duration and volume of chest tube drainage after surgical intervention. The investigated factors included age and weight at the time of operation, anatomical diagnosis, preoperative oxygen saturation, mean pulmonary artery pressure, ventricular end-diastolic pressure, fenestration, cardiopulmonary bypass time, conduit size, postoperative pulmonary artery pressure, administration of angiotensin-converting enzyme inhibitors, and postoperative infection. Associations between these factors and persistent pleural effusion after the extracardiac Fontan procedure were analyzed. Every patient suffered postoperative effusion. The median duration of postoperative chest tube drainage was 9 days (range, 3-69 days), and the median volume was 12 mL kg(-1) x d(-1) (range, 2.0-37.5 mL x kg(-1) d x (-1)). Thirty-seven (38.9%) patients had pleural drainage for more than 15 days, and the volume in 35 (36.8%) patients exceeded 25 mL x kg(-1) x d(-1). Nineteen (20%) patients required placement of additional chest tubes for re-accumulation of pleural effusion after removal of previous chest tubes. Fifteen (17.8%) patients were hospitalized again due to pleural effusion after discharge. The median length of hospital stay after the operation was 14 days (range, 4-78 days). Multivariate analysis results showed that non-fenestration, low preoperative oxygen saturation, and postoperative infections were independent risk factors for prolonged duration of pleural drainage (P < 0.05). Long cardiopulmonary bypass time, non-fenestration, small conduit size, and low preoperative oxygen saturation were independent risk factors for excessive volume of pleural drainage (P < 0.05). For reduing postoperative duration and volume of pleural drainage following Fontan procedure, it seems to be important to improve the preoperative oxygen saturation, use large size of conduit, shorten cardiopulmonary bypass time, and make fenestration during the operation, as well as avoid postoperative infections.

Pleural effusions, water balance mediators and the influence of lisinopril after completion Fontan procedures

To investigate whether the duration of pleural drainage after Fontan completion operations can be influenced by postoperative lisinopril administration or can be related to water balance hormone levels. In a prospective trial 21 patients scheduled for total cavopulmonary connection were randomized into two groups, with group I receiving lisinopril postoperatively, and group II receiving no angiotensin converting enzyme inhibitor. Plasma levels of antidiuretic hormone, renin and aldosteron were analyzed preoperatively and at four-time points postoperatively. Groups were comparable for age, preoperative saturation and pulmonary pressure, cardiopulmonary bypass time, cross-clamp time and preoperative hormone levels. Mean duration of pleural drainage was comparable for both groups (group I: 9.6+/-8 days vs group II: 10+/-7 days; p=0.78). The hormone profiles in each group changed significantly at 1 and 24h postoperatively compared to preoperative values (p<0.05), with no significant differences between the treatment groups. The duration of pleural drainage correlated significantly with hormone levels at 24h postoperatively, and with longer bypass times. At multivariate analysis only aldosteron and antidiuretic hormone level at 24h came out as factors reaching significance for prolonged pleural drainage. The Fontan completion induces significant changes in the levels of antidiuretic hormone, aldosteron and renin. Prolonged drainage correlates significantly with elevated levels of aldosteron, renin and antidiuretic hormone postoperatively, and with longer bypass time, but is not influenced by lisinopril. The eventual adjunct therapy with aldosteron antagonists warrants further study.

Reply to Goksel and Tireli

We would like to thank Goksel and Tireli for their recent comments [1] on our recently published article [2]. We do not have any experience with off-pump surgery for cavopulmonary shunt or Fontan completion. This technique certainly has attractions of avoiding the potential deleterious effects of cardiopulmonary bypass as highlighted, particularly in terms of pulmonary vascular resistance and inflammatory response. It would be interesting to know the exact impact on the amount and duration of pleural drainage. Our greatest concernwith the off-pump technique is that is does not really allow for any reconstruction or plasty of the pulmonary arteries, which frequently needs addressing at the time of surgery, particularly following the Norwood procedure. We prefer a bypass approach which is close to normothermia on the beating heart and feel this allows for accurate assessment of the PAs and where necessary augmentation and reconstruction. It also guarantees maintenance of cardiac output should there be problems with bleeding or accessing the IVC. We await further evidence to evaluate the benefits and risks of offpump Fontan surgery.

Outcomes of the Fontan Procedure Using Cardiopulmonary Bypass with Aortic Cross-Clamping

Avoidance of cardiopulmonary bypass (CPB) and aortic cross-clamping during the Fontan procedure has been advocated to improve outcomes. We continue to use CPB with aortic cross-clamping for the Fontan procedure. We performed a review of patients undergoing the Fontan procedure between January 1, 2000 and December 31, 2004. The Fontan procedure was performed in 160 patients. The median age was 2.2 years (range, 1.0 to 29.1 years). Hypoplastic left heart syndrome or a variant was present in 114 patients (71%), and heterotaxy was present in 19 (12%). CPB and modified ultrafiltration were used in all patients. Aortic cross-clamping was used in 154 (96%) of 160 patients and deep hypothermic circulatory arrest (DHCA) in 132 (83%). A lateral tunnel Fontan was performed in 69 patients (43%) and an extracardiac Fontan in 91 (57%). A fenestration was created in 144 patients (90%). Two patients died. Freedom from death or takedown was 98% (157/160). Median duration of pleural drainage was 2 days (range, 1 to 44 days) and was more than 14 days in 16 patients. Median duration of hospitalization was 6 days (range, 3 to 55 days). The small number of deaths precluded assessment of risk factors for mortality. By multivariable analysis, risk factors for pleural drainage longer than 3 days were extracardiac connection (p < 0.001) and increasing mean pulmonary artery pressure before the Fontan procedure (p = 0.033). By multivariable analysis, risk factors for hospitalization for more than 7 days were extracardiac connection (p = 0.003), increasing duration of total support (CPB and DHCA, p = 0.027), and decreasing systemic oxygen saturation before the Fontan procedure (p = 0.048). The Fontan procedure can be performed using CPB and aortic cross-clamping with low morbidity and mortality.

Clinical characteristics and outcomes of empyema thoracis in 117 patients: A comparative analysis of tuberculous vs. non-tuberculous aetiologies

Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema. Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression. One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis. Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.

Early Cavopulmonary Anastomosis After Norwood Procedure Results in Excellent Fontan Outcome

Children with univentricular hearts and aortic arch obstruction are treated sequentially with Norwood procedure, superior cavopulmonary anastomosis (SCPA), and Fontan operation. Early SCPA results in lower initial O2 saturation and longer hospitalization, but not increased mortality. We sought to determine the impact of early SCPA on Fontan candidacy and outcomes. Eighty-five consecutive patients undergoing Norwood operation between January 1998 and February 2003 were divided into group 1 (SCPA at less than 4 months, n = 33) and group 2 (SCPA at more than 4 months, n = 52). Of the original cohort, 69 have undergone Fontan operation, 7 await Fontan, 1 was transplanted, 3 are not Fontan candidates, and 5 died late after SCPA. Group 1 (n = 25) and group 2 (n = 44) patients who have completed Fontan operation were compared for preoperative and perioperative variables: age, size, O2 saturation, pulmonary artery pressure and size, prevalence of tricuspid regurgitation and ventricular dysfunction, extubation rate in operating room, duration of pleural drainage, hospital stay, and discharge O2 saturation. Late functional status and ventricular function were also compared. Survival was compared for original groups 1 and 2. There were no differences for any preoperative or perioperative variable, or late functional assessment. Actuarial survival at 6 years was also not different (88% +/- 5% for group 1 and 94% +/- 4% for group 2, p = 0.72). Although initially more cyanotic and hospitalized longer than older peers, younger SCPA patients achieve clinical equivalence by the time of Fontan operation and afterward. We conclude that both short- and long-term outcomes support performance of early SCPA.

Video-assisted thoracoscopic versus open surgery for persistent ductus arteriosus

Background/Purpose The aim of this study is to compare the experience with video-assisted thoracoscopic surgery (VATS) for patent ductus arteriosus (PDA) since 1995 with the results of conventional open surgery from the preceding 10 years. Methods The records of 60 children who underwent standard posterolateral muscle splitting thoracotomy and ligation of PDA in 1986-1995 were reviewed for the study. The data on 50 children who underwent VATS PDA ligation since 1995 were collected prospectively. Results All patients survived. Ductal bleeding requiring sutures with patches occurred once in the open surgery group. Two patients in the VATS group underwent immediate rethoracoscopy and clipping because of residual ductal flow in the postoperative echocardiography. Complications in the VATS group included 6 (12%) recurrent laryngeal nerve injuries (3 transient) and 2 chylothoraces. One patient in each group underwent open reoperation because of residual ductal flow 1 year after the initial operation. The operative time, duration of recovery room/neonatal intensive care unit care, duration of pleural drainage, and length of hospital stay were significantly shorter in the VATS group. Conclusions VATS PDA ligation gave results equal to traditional open surgery with a shorter operative time, faster recovery, and shorter hospital stay. More complications, especially recurrent laryngeal nerve injuries, occurred in the VATS group.

Videothoracoscopic Resection of Stage II Thymoma: Prospective Comparison of the Results Between Thoracoscopy and Open Methods

Although videothoracoscopic (VTS) resection of Masaoka stage I thymoma has been reported to be a less invasive method than open thoracotomy and to achieve a comparable surgical outcome, the usefulness of this method in the treatment of stage II thymoma has not yet been prospectively evaluated. We therefore compared the VTS and open (median sternotomy) methods to see whether VTS resection could be used as successfully to treat stage II thymoma disease.Patients (11 women and 11 men) with stage II thymoma were prospectively enrolled between November 1999 and September 2004. Of these, 12 patients (the VTS group) underwent tumor resection using a three-port endoscopic technique, and 10 patients (the open group) underwent tumor excision using a standard sternotomy approach. The diagnosis of all resected thymoma lesions and their stage were confirmed by histopathogic examination.Neither group experienced mortality or any major morbidity. The difference in mean age (+/- SD) between the VTS and open groups (40.2 +/- 16.3 years and 47.7 +/- 8.5 years, p = 0.202); mean operation time (193.3 +/- 79.6 min and 207.5 +/- 85.8 min, p = 0.692); mean duration of pleural drainage (4.2 +/- 2.1 days and 4.6 +/- 2.1 days, p = 0.702); and mean duration of postoperative hospital stay (6.8 +/- 2.3 days and 8.9 +/- 4.4 days, respectively; p = 0.157) were not statistically significant. However, mean intraoperative blood loss amounts were statistically different (119.2 +/- 70.6 mL and 238.5 +/- 110.2 mL, respectively; p = 0.006). During the mean follow-up period of 33.9 +/- 19.7 months, all patients survived without sign of recurrence, and the mean survival time was not statistically significant (32.3 +/- 22.0 months and 35.8 +/- 17.5 months, respectively; p = 0.686).Using careful and skillful technique, the VTS method is an effective treatment of stage II thymoma.

Prospective Comparison Between Endosuturing and Endostapling in Treating Primary Spontaneous Pneumothorax

Direct management of ruptured pulmonary blebs remains the definitive treatment for spontaneous pneumothorax. We compared endosuturing and endostapling performed via thoracoscopy to determine if suture closure of the blebs without resection was sufficient to treat primary spontaneous pneumothorax. Nine female and forty-nine male prospective patients were prospectively enrolled into two groups between July 1999 and May 2003. The patients in the suturing group were treated with an endoscopic suturing technique to close existing blebs. Patients in the stapling group underwent endoscopic stapling to excise the blebs. Only three ports were needed for each procedure. Neither group experienced mortality or any major morbidity. There were no significant clinical differences between the suturing and stapling groups. The intra-operative blood loss was not significantly different (32.9+/-53.9 and 13.6+/-21.8 mL, respectively, P = 0.079). The duration of pleural drainage was not statistically significant (2.7+/-1.2 and 2.3+/-2.0 days, respectively, P = 0.369). The length of postoperative hospital stay was also not statistically significant (4.2+/-1.5 and 3.8+/-2.4 days, respectively, P = 0.386). However, the operative time was significantly longer in the suturing group (135.0+/-53.8 and 89.0+/-35.6 minutes, respectively, P < 0.05). In each group, there were two cases of recurrence during the 21.5+/-12.1 month followup period, all of which recovered well after retreatment. We believe that this is the first prospective study on thoracoscopic suture closure of blebs. By imbricating and buttressing the blebs without resection, the endosuturing method represents an effective way to treat primary spontaneous pneumothorax.

Videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax: long-term results

Background The goal of this study was to evaluate the long-term efficiency of videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax. Methods From July 1991 to December 1997, 182 patients with primary spontaneous pneumothorax were treated by a single technique at our institution. Seven patients had single-stage bilateral procedures and 11 other patients had staged bilateral procedures. Indications for operation were first episode with prolonged air leak, incomplete lung reexpansion, or job restrictions (n = 59), first ipsilateral recurrence (n = 57), second or third ipsilateral recurrence (n = 34), contralateral recurrence (n = 25), synchronous bilateral pneumothorax (n = 3), hemopneumothorax (n = 3), and tension pneumothorax (n = 1). All patient data were reviewed retrospectively, and 167 patients were available for late follow-up (92%). Results Mean operative time was 57 ± 19 minutes Conversion to thoracotomy was required in 1 patient (0.6%). Mean duration of pleural drainage was 5.8 ± 1.2 days (range, 4 to 26 days), and mean postoperative stay was 7.7 ± 1.6 days (range, 6 to 31 days). Postoperative complications occurred in 50 patients (27.4%), the most frequent being prolonged air leak (14.8%), and in-hospital mortality was 0%. After a mean follow-up of 93 ± 22 months (range, 57 to 134 months; median, 84 months), five ipsilateral recurrences were noted (3%). Three recurrences occurred within 12 months of videothoracoscopy and required reoperation. Two patients had partial pneumothorax recurrence at 39 and 58 months, and were treated conservatively with chest tube insertion and tale slurry. After 1 year, 10.7% of patients complained of chronic chest pain or discomfort, although none was taking pain medication after 3 months. Most patients (89.8%) were satisfied or very satisfied of their operation. All patients had returned to sport activities within 2 years. Conclusions Videothoracoscopic bullectomy and pleural abrasion is a reliable and safe method to treat primary spontaneous pneumothorax. Long-term recurrences occur with an acceptable rate that compares with results after limited thoracotomy. Chronic chest pain or discomfort is unpredictable and may represent a problem in a few patients.

Is captopril useful in decreasing pleural drainage in children after modified Fontan operation?

We performed a retrospective cohort study to assess the relation between administration of angiotensin-converting enzyme inhibitors and duration of pleural drainage in the early postoperative period in patients who underwent a modified Fontan operation at our institution from 1990 through 1996. This study failed to show that administration of captopril decreased the duration of pleural drainage in patients after a modified Fontan operation.

Pleural drainage after repair of tetralogy of Fallot.

Prolonged pleural effusion after congenital heart surgery results in extended hospitalization. Pleural drainage was evaluated in 39 consecutive patients undergoing repair of tetralogy of Fallot, to identify risk factors for persistent pleural effusion. Duration and amount of drainage was examined by the Kaplan-Meier method and risk factors were evaluated by univariable and multivariable analyses. Median time of pleural drainage was 6.1 days, range 3 to 42 days. Duration of pleural drainage correlated with length of hospital stay (p < 0.0001). Postrepair right atrial pressure (p = 0.018) and preoperative hemoglobin (p = 0.035) were risk factors for persistent drainage. The presence of a previous right thoracotomy reduced drainage duration (p = 0.034). Prolonged mechanical ventilation increased the average daily volume of effusion (p < 0.0001). In conclusion, prolonged pleural effusion is an important morbidity factor after repair of tetralogy of Fallot. Bilateral chest tube insertion is indicated in patients with high preoperative hemoglobin and elevated postrepair right atrial pressure. Right thoracotomy is the preferred surgical approach when a preliminary palliative shunt is required.

Thoracoscopic Wedge Lung Biopsy in the Diagnosis of Pulmonary Parenchymal Disease

We reviewed our experience in 20 patients [12 women and eight men, aged 52 ± 17 years (mean ± SD); range, 17–81 years] who underwent thoracoscopic wedge lung biopsy for pulmonary parenchymal disease. Fourteen patients were referred as outpatients and six patients were inpatients at the time of biopsy. For the outpatients, the mean room air arterial oxygen tension (Pao2) was 62 ± 14 mm Hg, the mean percent predicted forced vital capacity (FVC) was 70 ± 20, and the mean percent predicted carbon monoxide diffusing capacity of lung (DLco) was 52 ± 16. The mean duration of chest tube drainage was 1.7 ± 2.4 days, with 12 (86%) of 14 chest tubes removed in 1 day and the mean length of hospital- ization was 3.1 ± 2.7 days, with 10 (71%) of 14 patients discharged in 2 days. For the inpatient referrals, the mean duration of pleural drainage was 14 ± 17 days (range, 2–40) and mean length of hospitalization after biopsy was 23 ± 25 days (range, 3–64). A clinically relevant diagnosis was made in 19 (95%) of 20 patients. Management was influenced by the biopsy results in 18 (90%) of 20 patients. Complications occurred in two patients: one had a prolonged air leak that resolved spontaneously with continuous suction, and one during general anesthesia developed a mucous plug that was removed bronchoscopically. We conclude that thoracoscopic wedge lung biopsy is an effective and efficient method for evaluating parenchymal lung disease and that it can be performed safely by properly trained and experienced pulmonary physicians.