Postoperative Pleural Effusion Research Articles

Year in review 2011: Respiratory infections, tuberculosis, pleural diseases, bronchoscopic intervention and imaging

This review highlights important contributions published in Respirology and other reputable respiratory journals in 2011 in four principle respiratory medicine areas, namely pulmonary infections, tuberculosis (TB), pleural diseases and chest imaging/interventional pulmonology. The articles have been selected for their insight, reliability and potential impact on clinical practice. From a total of 111 original articles and 40 review papers published in Respirology that year, 34% and 40%, respectively, were devoted to the earlier topics.

Reduction in Postoperative High-Density Lipoprotein Cholesterol Levels in Children Undergoing the Fontan Operation

Despite the emerging relevance of high-density lipoprotein (HDL) in the inflammatory cascade and vascular barrier integrity, HDL levels in children undergoing cardiac surgery are unexplored. As a measure of HDL levels, the HDL-cholesterol (HDL-C) in single-ventricle patients was quantified before and after the Fontan operation, and it was determined whether relationships existed between the duration and the type of postoperative pleural effusions. The study prospectively enrolled 12 children undergoing the Fontan operation. Plasma HDL-C levels were measured before and after cardiopulmonary bypass. The outcome variables of interest were the duration and type of chest tube drainage (chylous vs. nonchylous). The Kendall rank correlation coefficient and the Wilcoxon rank sum test were used. There were 11 complete observations. The median preoperative HDL-C level for all the subjects was 30 mg/dl (range, 24-53 mg/dl), and the median postcardiopulmonary bypass level was 21 mg/dl (range, 14-46 mg/dl) (p = 0.004). There was a tendency toward a moderate inverse correlation (-0.42) between the postcardiopulmonary bypass HDL-C level and the duration of chest tube drainage, but the result was not statistically significant (p = 0.07). In the chylous effusion group, the median postcardiopulmonary bypass HDL-C tended to be lower (16 vs. 23 mg/dl; p = 0.09). After the Fontan operation, the plasma HDL-C levels in children are significantly reduced. It is reasonable to conclude that the reduction in HDL-C reflects reduced plasma levels of HDL particles, which may have pertinent implications in postoperative pleural effusions given the antiinflammatory and endothelial barrier functions of HDL.

腹腔鏡下膵体尾部切除術後に遅発性に発症した両側膵性胸水の1例

症例は60歳代，女性．自己免疫性溶血性貧血および膵尾部嚢胞性腫瘍の診断にて腹腔鏡下膵体尾部切除術を行い，術後合併症なく退院した．術後84日目に全身倦怠，食欲不振により再入院となり，4日目に突然両側胸水貯留による呼吸不全・循環不全を呈した．胸腔ドレナージにて症状は改善したが胸水アミラーゼが高値であり，膵性胸水を疑い内視鏡的逆行性膵管造影を行った．膵管造影では膵体部膵管から右胸腔内への造影剤流出を認め，経鼻膵管ドレナージチューブ挿入，絶食，および酢酸オクトレオチド投与による保存的治療を開始した．膵液ドレナージ後胸水排出はなくなり，挿入後36日目に経鼻膵管ドレナージチューブを抜去，その後も胸水の増加は認めなかったが，日常生活動作の低下が著しく再入院後155日目に退院した．術後遅発性に発症した膵性胸水は稀な病態であるが，重篤な併存疾患を持つ患者の膵切除後において念頭に置くべき病態と考えられる．

Diaphragmatic Surgery During Primary Cytoreduction for Advanced Ovarian Cancer: Peritoneal Stripping Versus Diaphragmatic Resection

Standard approach for medically stable advanced ovarian cancer patients should be primary cytoreduction following platinum-based chemotherapy. The aim of surgical effort should be the complete removal of all visible disease. Our objective was to compare perioperative features, postoperative complications, and secondarily oncological outcomes of patients who underwent diaphragmatic stripping with those who underwent diaphragmatic resection for advanced ovarian cancer. One hundred twelve cases were identified, among them 79 underwent diaphragmatic stripping and 33 underwent diaphragmatic full-thickness resection. Data collected included patients' age, all perioperative details and pathological findings, International Federation of Gynecology and Obstetrics stage, adjuvant therapy, and follow-up data. Larger residual tumors (mean, 5.1 vs 1.6 mm, respectively; P < 0.01) but shorter operating time (25 minutes shorter operative time, P = 0.07) were observed in the stripping group. Higher postoperative pleural effusions rates (63.6% vs 37.9%, P = 0.01), but no differences in the remaining complications, were observed in the resection group. After a mean of 31 months of follow-up, disease-free survival rates were 27.8% in the stripping group and 39.4% in the resection group (P = 0.04). No significant differences were observed for overall survival. Diaphragmatic surgery at the time of primary cytoreductive surgery for advanced ovarian cancer may contribute to the achievement of complete cytoreduction with low perioperative complication rate; full-thickness resection is preferable if peritoneum stripping will not achieve a complete removal of the disease.

Subarachnoid-Pleural Fistula: Applied Anatomy of the Thoracic Spinal Nerve Root

Subarachnoid-pleural fistula (SPF) is a rare complication of chest or spine operations for neoplastic disease. Concomitant dural and parietal pleural defects permit flow of cerebrospinal fluid into the pleural cavity or intrapleural air into the subarachnoid space. Dural injury recognized intraoperatively permits immediate repair, but unnoticed damage may cause postoperative pleural effusion, intracranial hypotension, meningitis, or pneumocephalus. We review two cases of SPF following surgical intervention for chest wall metastatic disease to motivate a detailed review of the anatomy of neural, osseous, and ligamentous structures at the intervertebral foramen. We further provide recommendations for avoidance and detection of such complication.

The role of postoperative furosemide therapy in the treatment of pleural effusion following kyphosis/scoliosis surgery

Retrospective analysis of data to determine if the use of postoperative furosemide therapy decreases the incidence of thoracocentesis in children and adolescents undergoing kyphosis or scoliosis surgery. One of the potential complications seen in patients undergoing scoliosis or kyphosis surgery is the development of a clinically symptomatic postoperative pleural effusion requiring thoracocentesis, which is an invasive procedure that is associated with discomfort to the patient and a minimal risk of an iatrogenic pneumothorax. We retrospectively reviewed the medical records and X-rays of 190 patients who had undergone corrective surgery for AIS/kyphosis. All patients underwent an ASF or an APSF or a PSF with a minimum 3 level costoplasty. We compared the rate of thoracocentesis in group 1 (no furosemide; 161 patients) to that in group 2 (furosemide; 29 patients). Follow-up chest radiographs were evaluated for a decrease or resolution of the effusion. In group 1, 26 out of the 161 patients required thoracocentesis (16%); in group 2, only 1 out of the 29 patients underwent thoracocentesis (3.4%). Postoperative furosemide in patients who undergo significant pleural manipulation during spinal deformity surgery may decrease the incidence of clinically symptomatic pleural effusion requiring thoracocentesis. This study represents a true trend; however, a high level of significance can only be achieved by performing a larger randomized controlled study.

Prognostic significance and correlations of neurohumoral factors in early and late postoperative period after Fontan procedure

We focused on neurohumoral activity and its clinical correlates early and late after fenestrated, lateral intra-atrial total cavopulmonary connection (TCPC). Between 2007 and 2010, we prospectively studied 28 early and 48 late postoperative TCPC patients. Plasma concentrations of vasopressin, endothelin-1, proBNP, proANP were determined. We reviewed clinical data to determine relationship between neurohumoral activation and clinical status after TCPC. There was a significant influence of preoperative ventricular end-diastolic pressure (VEDP) (P=0.008) and vasopressin concentration (P=0.02) on the appearance of prolonged pleural effusions. A significant correlation between a combined predictor (a product of preoperative vasopressin concentration and VEDP) and time of effusions (r=0.59, P=0.006) was found. The mean respiratory equivalent of carbon dioxide at peak exercise (VE/VCO(2peak)) was significantly lower in patients operated before the second year of life compared to patients operated after two years of age (27.5±1.39 vs. 48.6±3.86; P=0.039). There was a significant correlation of endothelin-1 (r=0.84; P=0.008) and proBNP (r=0.88; P=0.02) concentrations with VE/VCO(2peak). The prolonged postoperative pleural effusions can be predicted based on the product of preoperative vasopressin concentration and VEDP. Exercise performance is related to the age at TCPC. Endothelin-1 and proBNP can be useful for identification of high-risk Fontan patients.

Management of Postoperative Pleural Effusion in Lung Cancer

Objective To study the treatment of postoperative pleural effusion in lung cancer.Methods Sixty-eight cases of lung cancer with postoperative pleural effusion were collected from January 2006 to June 2009 in Union hospital of Tongji Medical College.The treatment methods of pleural effusion included bronchoscopy,antibiotics adjustment,pleurodesis with talcum,DDP and 50% glucose through a transchest catheter,chest clearance and simultaneously bronchial stump embedment with pericardium or azygos vein.Results Sixty-six patients were cured,although 2 patients failed to remove pleural effusion.Conclusion Postoperative pleural effusion,a common complication induced by surgery in lung cancer,was able to be controlled by strongly treatment.

Surgical treatment of multiple primary hypopharyngeal cancer and thoracic esophageal cancer: a report of 7 cases

Objective To investigate the clinicopathological characteristics,diagnosis and surgical treatment of multiple primary hypopharyngeal cancer and thoracic esophageal cancer. Methods Seven male patients with multiple primary hypopharyngeal cancer and thoracic esophageal cancer underwent surgical treatment during Jan. 2002 to Jan. 2008. Their clinical data,including the adjuvant examination method,clinical staging,pathological types,and operative methods,postoperative complications,and long-term outcomes,were retrospectively analyzed. Results Six patients were confirmed to have the disease before operation,and one patient was pathologically confirmed after operation. All patients had squamous cell carcinoma,with all the thoracic esophageal lesions and four hypopharyngeal lesions being well-differentiated,and three hypopharyngeal lesions being moderately differentiated. All cases underwent total laryngectomy,total hypopharyngectomy and total esophagectomy,and were reconstructed with gastropharyngostomy. There was no perioperative death and the swallowing function recovered satisfactorily after operation in all cases. One patient had postoperative pleural effusion and one had postoperative wound infection,which were cured after conservative treatment. All patients were followed up. One patient survived tumor-free for five years,two patients died two years after operation due to recurrence,and one died 10 months after operation due to local recurrence and bleeding. Conclusion Multiple primary hypopharyngeal cancer and thoracic esophageal cancer have similar characteristics,and various adjuvant examinations should be used routinely to avoid missed diagnosis. Total hypopharyngectomy and total esophagectomy combining reconstruction with gastropharyngostomy are easy to perform; they can be the first choice for the condition.

Venoatrial Shunt-Assisted Cavopulmonary Anastomosis

The bidirectional Glenn shunt operation is conventionally performed under cardiopulmonary bypass. Between June 2007 and September 2009, 218 consecutive patients underwent off-pump bidirectional Glenn shunt institution for single ventricle with pulmonary stenosis complex. Their mean age was 4.72 ± 1.80 years (range, 4 months to 6 years) and median weight was 10.12 kg (range, 4.1-19 kg). A temporary shunt was created between the innominate vein and the right atrium, with a 3-way connector for de-airing. Fifty-five patients had bilateral cavae. The mean internal jugular venous pressure on clamping the superior vena cava was 24.69 ± 1.81 mm Hg. Continuous end-tidal CO₂ and O₂ saturation were monitored. Adequate oxygen saturation and blood pressure were maintained by optimizing inotropics, volume, and inspired oxygen. The mean duration of ventilation was 10.17 ± 8.96 h (range, 1-73 h). There were no gross neurological complications. Postoperative pleural effusion developed in 6 (2.75%) patients, and 4 (1.83%) had nodal rhythm. Four (1.83%) patients died in the immediate postoperative period due to low cardiac output syndrome. Venoatrial shunt-assisted bidirectional Glenn shunt surgery can be performed safely by optimizing intraoperative management strategies. It is economical and avoids the deleterious effects cardiopulmonary bypass.

Miniaturized biocompatible cardiopulmonary bypass for the Fontan procedure

Postoperative inflammatory response and perioperative systemic edema are the risks of failed Fontan circulation. We evaluated the efficiency of the miniaturized, poly-2-methoxyethylacrylate (PMEA)-coated cardiopulmonary bypass (CPB) circuit, which we devised in 2003, in the Fontan circulation. Thirty-seven patients who underwent the Fontan procedure between March 1996 and December 2006 were divided into two groups: one consisting of patients with a priming-volume >250 m on uncoated conventional bypass (group C; n = 20), and one consisting of those with miniaturized (<200 ml) and PMEA-coated circuits (group M; n = 17). We compared the body weight gain (%BWG), minimum platelet count, maximum postoperative C-reactive protein (CRP), and minimum hematocrit (Hct) levels during the operation, maximum white blood cell (WBC) count, and postoperative pleural effusion, between the two groups. Stepwise multiple logistic regression analyses were used to investigate the most affecting factors. The %BWG and CRP levels were significantly lower in group M (P = 0.047 and P = 0.012, respectively). The minimum platelet count was significantly higher in group M (P = 0.012). There were no significant differences in postoperative pleural effusion, minimum Hct, or maximum WBC. The miniaturized biocompatible CPB system reduced perioperative inflammatory responses.

Incidental events of diaphragmatic surgery in 82 patients with advanced ovarian, primary peritoneal and fallopian tubal cancer

Surgical resections, such as peritoneal stripping (peritonectomy) are performed for disseminated diaphragmatic lesions of advanced ovarian cancer. This study retrospectively investigated the incidental events of diaphragmatic surgery. The records of patients with advanced mullerian carcinomas, including ovarian, primary peritoneal and fallopian carcinomas, who underwent diaphragmatic surgery were reviewed. Based on our criteria, stripping was performed for surface disease on the diaphragm, and full-thickness resection was performed for bulky disease. In certain cases, both procedures were performed. We analyzed intra- and post-operative incidental events in 82 patients. The χ(2) and Fisher's exact tests were used in the statistical analysis. There were 82 stage III-IV cases of which 56 patients underwent stripping, 12 underwent full-thickness resection and 14 patients underwent both procedures. Unexpected open chest surgery following stripping occurred in 1 out of 63 patients (1.6%) in the primary, 4 out of 13 patients (30.8%) in the interval and 0 out of 6 patients (0.0%) in the secondary debulking surgery groups. The incidence of unexpected open chest surgery was high in the interval debulking surgery group (p<0.001). Regarding post-operative events, accumulation of pleural effusion was identified in 43 patients (52.4%). The incidence of pleural effusions was not significantly different between the two procedures. No complications were encountered, nor was a chest tube required, during unexpected open chest surgery and postoperative pleural effusions. Therefore, it was concluded that special attention should be paid during interval debulking surgery even though it was possible for surgical resections of diaphragmatic lesions to be performed safely.

A contemporary comparison of the effect of shunt type in hypoplastic left heart syndrome on the hemodynamics and outcome at Fontan completion

We previously reported no difference in morbidity or mortality in a cohort of infants undergoing stage 1 and 2 reconstructions for hypoplastic left heart syndrome with either a modified Blalock-Taussig shunt or a right ventricular to pulmonary artery conduit. This article compares the hemodynamics and perioperative course at the time of the Fontan completion and reports longer-term survival for this cohort. We retrospectively reviewed the hospital records of all patients who underwent stage 1 reconstruction between January 2002 and May 2005 and subsequent surgical procedures, as well as cross-sectional analysis of hospital survivors. A total of 176 patients with hypoplastic left heart syndrome or a variant underwent stage 1 reconstruction with either modified Blalock-Taussig shunt (n = 114) or right ventricular to pulmonary artery conduit (n = 62). Shunt selection was at the discretion of the surgeon. The median duration of follow-up was 58 months (range 1-87 months). By Kaplan-Meier analysis, shunt type did not influence survival or freedom from transplant at 5 years (right ventricular to pulmonary artery conduit 61%; 95% confidence limit, 47-72 vs modified Blalock-Taussig shunt 70%; 95% confidence limit, 60-77; P = .55). A total of 107 patients underwent Fontan (69 modified Blalock-Taussig shunts and 38 right ventricular to pulmonary artery conduits) with 98% (105/107) early survival. Patients with a right ventricular to pulmonary artery conduit shunt pre-Fontan had higher pulmonary artery (13 +/- 8 mm Hg vs 11 +/- 3 mm Hg, P = .026) and common atrial (8 +/- 2.3 mm Hg vs 6.8 +/- 2.7 mm Hg, P = .039) pressures. By echocardiography evaluation, there was more qualitative moderate to severe ventricular dysfunction (right ventricular to pulmonary artery conduit 31% [12/36] vs modified Blalock-Taussig shunt 17% [11/67], P = .05) and moderate to severe atrioventricular valve regurgitation (right ventricular to pulmonary artery conduit 40% [14/35] vs modified Blalock-Taussig shunt 16% [11/67], P = .01) in the right ventricular to pulmonary artery conduit group. Use of diuretic therapy, angiotensin-converting enzyme inhibition, reflux medications, and tube feedings were not different between groups. Overall, 5 patients underwent heart transplantation (right ventricular to pulmonary artery conduit 4 vs modified Blalock-Taussig shunt 1, P = .1) before Fontan. There was no difference in age or weight at Fontan, bypass time, intensive care unit or hospital length of stay, postoperative pleural effusions, or need for reoperation between groups. Interim analyses continue to suggest there is no survival advantage of one shunt type compared with the other. Longer-term follow-up of a randomized patient population remains of utmost importance.

Multi-level corpectomies and reconstruction via a single posterolateral approach

The surgical treatment of ventral spinal canal compression has traditionally required either an anterior or combined anterior–posterior decompression and stabilization. These types of approaches carry a significant morbidity and may not be appropriate for all patients. We report our experience with multi-level corpectomies and reconstruction performed via a single, posterolateral approach. A retrospective review was performed of six consecutive patients at a single institution who were treated for ventral multi-level spinal cord compression via a single posterolateral approach. All six patients underwent reconstruction and stabilization with an expandable cage and posterior fixation. Five patients had metastatic cancer with spinal cord compression and one patient had osteomyelitis with a ventral epidural abscess and vertebral body collapse. All patients underwent 2-level corpectomies. Pre-operative and post-operative neurologic function and stabilization construct integrity were analyzed. All patients had successful decompression and stabilization and there were no hardware complications. Three peri-operative complications were encountered: post-operative pleural effusion needing thoracostomy drainage, transient leg paresis that resolved at 2months and a post-operative wound infection needing operative debridement. At last follow-up all patients had improvement or stabilization of their neurological function. Long-term follow-up was limited by the progression of metastatic disease and death in all the patients with cancer. This study demonstrates that symptomatic improvement can be achieved in select patients requiring multi-level corpectomies when using a single posterolateral approach with expandable cage reconstruction and posterior stabilization.

Right postoperative pleural effusion following laparoscopic appendicectomies: a case series

Pleural effusion is not a commonly reported complication of appendicectomy. In our experience, we have performed all forms of appendicitis by laparoscopy (n = 217) since August 2006. We report three consecutive cases of right postoperative pleural effusion, all of which occurred during the immediate postoperative course of a laparoscopic appendicectomy. All three patients presented a perforated appendicitis. The right postoperative pleural effusions seem to be linked to the laparoscopic approach, and can be explained by the cumulative effects of peritoneal lavage, pneumoperitoneum and Trendelenburg position. The first two cases were managed medically by intravenous antibiotic therapy. The third patient required a pleural drainage by thoracoscopy. Surgeons should be aware of this complication when operating perforated appendicitis by the laparoscopic method.

Early Pleural Effusions Related to the Myocardial Injury after Open-heart Surgery for Congenital Heart Disease

The degree of effusion immediately after cardiopulmonary bypass (CPB) can vary and may reflect several factors including the degree of myocardial injury. We compared the degree of pleural effusions after CPB to the overall myocardial injury as determined by serum cardiac troponin I (cTnI) levels after elective repair of a variety of congenital heart defects, including univentricular surgeries via cavopulmonary shunts. Serum was collected pre-CPB, post-CPB, and daily after that and cTnI level measured. The postoperative pleural effusion was measured each day until the chest tube was removed. Results. The 21 study patients were of average age of 5.5 years (+/-5.6). The duration of chest-tube drainage after open-heart surgery was 4.3 days (+/-3.5) and the amount was 2.4 mL/kg/hour (+/-2.9). For the biventricular repairs, cTnI levels on the postoperative day (POD) 1 best correlated with amount of effusion (n = 16, r = 0.5, P = 0.02) and the average (POD 0-3) cTnI levels with the total duration (n = 16, r = 0.4, P = 0.01) and also the amount (n = 16, r = 0.5, P = 0.02) of effusions. For the cavopulmonary shunts, the post-CBP cTnI level best correlated with the duration (n = 5, r = 0.8, P = 0.02) and amount (n = 5, r = 0.9, P = 0.02) of effusions. A cTnI level on the first postoperative day >or=15 microg/L was associated with effusions >2 days (sensitivity of 81% and specificity of 80%). We found that higher the cTnI released, especially >or=15 microg/L, longer the duration and greater the amount of early pleural effusions for a variety of congenital heart surgeries including cavopulmonary shunts. A number of factors may lead to excessive pleural effusions and the degree of myocardial injury may be one of them.

Ultrasound estimation of volume of postoperative pleural effusion in cardiac surgery patients

The aim of this study was to establish a practical simplified formula to facilitate the management of a frequently occurring postoperative complication, pleural effusion. Chest ultrasonography with better sensitivity and reliability in the diagnosis of pleural effusions than chest X-ray can be repeated serially at the bedside without any radiation risk. One hundred and fifty patients after cardiac surgery with basal pleural opacity on chest X-ray have been included in our prospective observational study during a two-year period. Effusion was confirmed on postoperative day (POD) 5.9+/-3.2 per chest ultrasound sonography. Inclusion criteria for subsequent thoracentesis based on clinical grounds alone and were not protocol-driven. Major inclusion criteria were: dyspnea and peripheral oxygen saturation (SpO(2)) levels < or = 92% and the maximal distance between mid-height of the diaphragm and visceral pleura (D > or = 30 mm). One hundred and thirty-five patients (90%) were drained with a 14-G needle if according to the simplified formula: V (ml)=[16 x D (mm)] the volume of the pleural effusion was around 500 ml. The success rate of obtaining fluid was 100% without any complications. There is a high accuracy between the estimated and drained pleural effusion. Simple quantification of pleural effusion enables time and cost-effective decision-making for thoracentesis in postoperative patients.

Upper abdominal surgery in advanced and recurrent ovarian cancer: Role of diaphragmatic surgery

Objective Upper abdominal spread of primary and recurrent ovarian cancer is often considered to be a major obstacle to achieve optimal residual disease at the end of surgery. In this study, we investigate the role of diaphragmatic debulking in the natural history of advanced and recurrent epithelial ovarian cancer patients, and the morbidity of this procedure according to clinico-surgical characteristics. Methods Data from 234 consecutive patients with primary and recurrent advanced ovarian cancer, operated at Catholic University of Rome and Campobasso from January 1, 2005 and December 31, 2008, were retrospectively reviewed. Results Eighty-seven patients (37.2%) underwent a diaphragmatic surgery. Median age was 55 years (range 37–76). Diaphragmatic debulking was performed in 50 out of 120 patients at primary surgery (41.7%), in 16 out of 74 at interval debulking surgery (21.6%) and in 21 out of 40 secondary cytoreductions (52.5%). In the whole study population optimal residual disease at the end of surgery was achieved. The most frequent post-operative complication was pleural effusion, observed in 37 patients (42.5%). Presence of a post-operative pleural effusion was correlated liver mobilization (52.3% vs. 16%; p < 0.0027) and large diaphragmatic disease (> 5 cm) removal (54.1% vs. 23.5%; p < 0.034). Conclusions Diaphragmatic surgery represents a crucial step in the debulking of advanced and recurrent ovarian cancer patients. Considering the natural history of advanced epithelial ovarian cancer and the rate of patients needing diaphragmatic debulking during primary cytoreduction, interval debulking surgery and secondary cytoreduction, this procedure should be present in the surgical repertoire of a gynecologic oncologist.

Impact of chest tube clearance on postoperative morbidity after thoracotomy: results of a prospective, randomised trial☆

In many centres of thoracic surgery, milking of chest tubes is performed to prevent them from blocking. The usefulness of chest tube clearance is discussed controversially. Therefore, we investigated the impact of postoperative chest tube milking on postoperative outcome in a prospective, randomised trial. Within a period of 11 months, 145 patients undergoing pulmonary resection through thoracotomy were included in the study. Two chest tubes each (silicone drainage, Redax, Mirandola, Italy) were placed in all patients (ventral tube 21Ch and dorsal tube 24Ch). Milking was applied to both chest tubes for 1 min every 2h within the first 48 h postoperatively and continuous suction of -20 cm H(2)O was maintained for 48 h. Duration of chest tube drainage, quantity and quality of effusion or air leakage, co-morbidity, length of hospital stay and 30-day postoperative morbidity and mortality were analysed. Furthermore, outcome was measured by assessment of chest radiographs at the time of discharge from hospital. Randomisation resulted in milking of chest tubes of 73 patients and in observation of chest tubes without any manipulation in 72 patients. Twenty-one patients had to be excluded from further analysis due to violation from the study protocol (n=9), necessity of replacement of a chest tubes (n=9) and re-operation for bleeding (n=3). The 30-day mortality rate was 1.4% in each group and the 30-day morbidity was 49.3% in the milking group and 52.8% in the observation group. Milking of chest tubes was not associated with a lower postoperative mortality or morbidity (p=0.99 and p=0.67, respectively; chi-square test). We observed a significant increase of postoperative pleural effusion drainage in the milking group 48 h after surgery (p=0.004; unpaired t-test). No correlation was seen between milking of chest tubes and the duration of chest tube drainage, quality of effusion, air leakage or length of hospitalisation. We showed for the first time that postoperative chest tube milking is associated with a significant increase of pleural fluid drainage. Postoperative morbidity and mortality was not improved and therefore chest tube milking cannot be recommended as a routine postoperative procedure.

The dynamics and clinical significance of alpha 2 plasmin inhibitor-plasmin complex and thrombin-antithrombin complex in postoperative pleural effusion following a pulmonary lobectomy

The overall incidence of postoperative alveolar air leakage (AAL) remains high; however, the mechanism regarding how to adequately heal such postoperative AAL remains to be elucidated. The aim of this study was to determine any correlations between the activity of the fibrinolytic and coagulation system in the postoperative pleural effusion and appearance or disappearance of postoperative AAL. This study prospectively investigated 25 patients who underwent a pulmonary lobectomy from July 2005 to March 2006. Pleural effusion was collected through the chest tube. Alpha 2 plasmin inhibitor-plasmin complex (PIC), as a fibrinolytic marker, and thrombin-antithrombin complex (TAT), as a coagulation marker, were measured. The activity of the coagulation system was higher than that of the fibrinolytic system. The concentration of TAT tended to increase (3rd vs 4th postoperative day [POD], P = 0.0907). The mean time of appearance and disappearance of postoperative AAL was 1.4 days and 3.2 days, respectively. The patients with postoperative AAL had a TAT level significantly below the average on the 3rd POD in comparison to the patients without postoperative AAL (P = 0.0163). Moreover, the concentration of TAT in patients with postoperative AAL was significantly lower than that in patients without postoperative AAL (1824.0 +/- 137.3 ng/ml vs 3444.0 +/- 287.6 ng/ml, P = 0.0113) on the 3rd POD. On the 4th POD, the concentration of TAT was almost same and there was no significance (P = 0.6759). This study demonstrated for the first time the course of the fibrinolytic and coagulation activity in the pleural effusion after a pulmonary lobectomy, and showed that the delayed activity of the coagulation system is associated with the appearance of the postoperative AAL.