Postoperative Pleural Drainage Research Articles

Protocols associated with no mortality in 100 consecutive Fontan procedures☆

Results of Fontan's procedure have improved considerably, but perioperative mortality still occurs, attributed to ventricular dysfunction, stroke, arrhythmia, thromboembolism, and multi-organ dysfunction. Our protocols of operative and intensive care unit management address these potential issues, and have been associated with zero mortality, even with many high-risk candidates. From 1996 to 2006, all Fontan patients were managed as follows: operative strategy based on aortic and single atrial cannulation, cooling on full-flow bypass, and hypothermic circulatory arrest to create the Fontan pathway. No direct caval cannulation. Use of central venous lines was completely avoided. Fresh whole blood was used for pump prime and for volume restoration. Inotropic and vasodilator therapy was continued for at least 48 h. Aspirin was used exclusively as anti-thrombotic therapy. Postoperative pleural drainage was accomplished with small pigtail catheters. The usual Fontan pathway was by lateral atrial tunnel (84), with extra-cardiac conduit when dictated by anatomy (16). One hundred Fontan operations were performed with no mortality. All patients were extubated by postoperative day 1. Hospital stay was 10+/-5 days. Complications were: bleeding (1), reintubation (1), emergent fenestration closure (1), pericardial effusion (4), and seizures (1). Risk factors included Fontan connection to one lung (3), diminutive pulmonary arteries (PAs) and unifocalized major aortopulmonary collateral arteries (MAPCAs) (1), discontinuous PAs (3), right ventricle dependent coronaries (3), neonatal pulmonary venous obstruction (3), Trisomy 21 (1), preoperative pacemaker dependence (2), and heterotaxy (10). No candidate was excluded. While many surgeons try to avoid bypass or aortic clamping when performing Fontan operations, the strategies we have employed facilitate safe accomplishment of Fontan's operation in diverse anatomic groups with multiple risk factors, with avoidance of operative mortality in 100 consecutive cases.

The Lateral Tunnel Fontan Procedure for Hypoplastic Left Heart Syndrome: Results of 100 Consecutive Patients

The Fontan procedure for hypoplastic left heart syndrome (HLHS) is well established. Multiple surgical techniques including extracardiac conduits and autologous tissue connections have been developed. We reviewed the results of 100 consecutive patients undergoing the lateral tunnel modification of the Fontan procedure at the University of Michigan. A cross-sectional retrospective study was performed for 100 consecutive patients identified in the University of Michigan Congenital Heart Surgery database with the diagnosis of HLHS. All patients had undergone a lateral tunnel Fontan procedure between June 2000 and August 2004. The medical record was reviewed to assess patient, procedural, and morphologic determinants of outcome. Hospital survival was 97% and intermediate-term survival was 96% with a median follow-up time of 34 months. Preoperative mean pulmonary artery pressure, right ventricular end diastolic pressure, aortic cross-clamp time, and tricuspid valve regurgitation were not associated with late right ventricular function or survival. Three patients required takedown of the lateral tunnel Fontan in the early postoperative period. A positive association was found between protein-losing enteropathy and prolonged (>2 weeks) postoperative pleural drainage (p = 0.035). No patient required cardiac transplantation or late intervention on the Fontan pathway. At the time of follow-up, 100% of patients were New York Heart Association class I or II and 90% were in normal sinus rhythm. The lateral tunnel Fontan procedure for HLHS can be performed with acceptable early and intermediate-term risk. There was a low prevalence of late rhythm disturbances and other complications. Protein-losing enteropathy and prolonged pleural drainage were associated.

Thoracoscopic palliative treatment of malignant pleural effusions

The aim of this study was to analyze the results of pleurodesis for malignant pleural effusion performed by surgeons. A series of 273 patients with malignant pleural effusion underwent thoracoscopy with the aim of performing a palliative pleurodesis. There were 94 males (34.4%) and 175 females (64.1%), ranging in age from 15 to 94 years (mean age: 60.6 years). The effusion was on the right side in 136 patients (49.8%), on the left side in 110 (40.3%), and bilateral in 27 (9.9%). Thoracoscopy was performed under general anaesthesia in all patients. Pleural biopsy was performed in two thirds of the patients (70.7%). Pleurodesis was produced by instillation of 5g of sterile asbestos-free talc; the chest tube was left in place a minimum of 3 days. It was removed when fluid drainage was less than 200 ml/24 h. Patients were usually discharged the day after chest tube removal. There was no intraoperative mortality. Two patients (0.7%) had intraoperative complications; 17 (6.2%) underwent a bilateral pleurodesis, and 10 (3.7%) had a pericardiopleural window. In 32 patients (11.7%) no pleurodesis was done, either because the lung did not properly re-expand (5.2%), or because of suspected infection, e.g., false membranes (1.9%), or because of multiple adhesions (4.6%). Finally, only 241 patients (88.3%) had a talc poudrage at the time of thoracoscopy. Duration of postoperative pleural drainage ranged between 1 and 11 days (mean: 3.64 days). The postoperative hospital stay ranged from 2 to 21 days (mean: 7.1 days). Pleural empyema occurred in 4 patients (1.5%) and was lethal in one patient. The mean follow-up period was 8.39 (7.2 months, and 172 patients had regular follow up. In this group, there were 24 recurrences (14%), 12 of which were treated by repeat pleurodesis. The results were very good in 133 patients (77.3%), acceptable in 35 patients (20.3%), and there was a failure in 4 patients (2.4%). Results of surgical thoracoscopy for malignant pleural effusion are good, with low morbidity. However, in debilitated patients, bedside talc slurry may be preferable.

Life expectancy of patients with malignant pleural effusion treated with video-assisted thoracoscopic talc pleurodesis

The aim of the current study was to analyse postoperative complications and survival after video-assisted thoracoscopic (VATS) talc pleurodesis for malignant pleural effusion. All patients with morphologically proven malignant pleural effusion who underwent VATS talc pleurodesis from November 1995 to November 2002 were included in retrospective analysis. VATS was performed in general anaesthesia and 5 g of asbestos-free talc was insufflated into the pleural cavity. Postoperative pleural drainage was used until fluid output was less than 100 ml/24 h. Ninety-eight patients (28 male and 70 female) with mean age 59.6 (range 18-82) years were included. Thirteen patients had a bilateral pleural effusion. The most common primary cancer sites were lung (30 cases), breast (25) and ovarium (11). Average duration of the operation was 46 (range 10-120) min. Median duration of postoperative drainage was 3 (range 1-20) days and postoperative hospitalisation 7 (range 3-70) days. Twenty-eight patients had postoperative complications (fever in 17 cases). In seven cases pleurodesis was ineffective. Median survival was 8.4 months. Six-, 12- and 24-month survival was 58% (95% CI [0.47-0.67]), 39% [0.29-0.49] and 20% [0.12-0.29], respectively. Survival data after VATS talc pleurodesis advocate use of this invasive treatment method despite the advanced stage of cancer.

Comparison between Flutter Valve Drainage Bag and Underwater Seal Device for Pleural Drainage after Lung Surgery

The purpose of the present study was to compare the use of a conventional underwater seal device with suction and a flutter valve drainage bag for pleural drainage after lung surgery. Altogether 59 patients undergoing elective lung surgery except pneumonectomy between February 2001 and April 2002 were prospectively randomized to receive postoperative pleural drainage by 28F chest tube(s) attached to underwater seal device placed on negative pressure of 15 cm of water or flutter valve drainage bag. Following withdrawal of four patients from the study, 55 patients were evaluated (31 patients in the underwater seal device group and 24 patients in the flutter valve drainage bag group). In the conventional underwater seal device group the mean drainage time was 2.6 (SD +/- 2.0) days and in the flutter valve drainage bag group the mean drainage time was 3.3 days (SD +/- 4.0); difference -0.8, 95% confidence interval (CI) -2.4 to 0.9. The mean length of hospitalization in the surgical ward was 3.6 (SD +/- 2.7) and 4.1 (SD +/- 4.4) days respectively (difference -0.5, 95% CI -2.5 to 1.4). The results of this study suggest that flutter valve drainage system is a safe and feasible alternative in managing postoperative air leaks and haemorrhage after lung surgery other than pneumonectomy if air leaks are not extremely massive.

Aortopulmonary collateral vessels and prolonged pleural effusions after modified Fontan procedures

Pleural effusions after the modified Fontan procedure are unpredictable, increase morbidity, and prolong hospital stay. To assess the relation between preoperative characteristics and postoperative pleural drainage, we performed a retrospective study of 71 patients who underwent Fontan procedures. Analyses revealed no significant relation between duration of effusion and age at Fontan, preoperative oxygen saturation, pulmonary artery pressure, ventricular end-diastolic pressure, type of Fontan, or prior cavopulmonary anastomosis. Patients with significant aortopulmonary collateral vessels evidenced by angiographic opacification of the pulmonary arteries or veins had more prolonged pleural drainage. The duration of the pleural drainage was significantly less in patients who had aortopulmonary collateral occlusion.

Pleural and Pulmonary Complications After Bilateral Internal Mamary Artery Grafting

The long-term patency of internal mammary artery (IMA) grafts in coronary bypass surgery is superior to that of saphenous vein grafts. To investigate if bilateral IMA grafting increases the complication rate, especially pleural problems, 100 patients with bilateral and 100 with unilateral IMA grafts were retrospectively studied. Preoperatively the groups did not differ in age, previous myocardial infarction, ejection fraction, NYHA classification or previous respiratory disease, but the coronary artery status was poorer in the bilateral IMA group. Postoperative pleural drainage was greater after bilateral IMA grafting (1074 vs. 497 ml, p less than 0.0001). Reoperation was required for bleeding in 10% of the patients with unilateral, and 20% of those with bilateral IMA grafting (p less than 0.05), and more blood was transfused in the latter group (5.9 vs. 4.7 units, p less than 0.01). Pleural effusion at discharge from hospital or 3 months postoperatively, pain in the sternotomy wound, pain on breathing and postoperative use of nitroglycerin did not differ significantly between the groups. Bilateral IMA grafting thus led to more bleeding and reoperations than single IMA grafting, but did not cause excessive pulmonary complications.