Chest Tube Removal Research Articles

Chest Ultrasound Can Reduce the Use of Roentgenograms in Postoperative Care After Thoracic Surgery

Roentgenography remains the standard imaging modality after thoracic surgery. Trials from intensive medicine proved a high accuracy of ultrasound examination in the diagnosis of various conditions. The assumption was that ultrasound examination could reduce the number of roentgenograms after thoracic surgery. This prospective study compared ultrasound examinations performed by thoracic surgeons with roentgenograms in the diagnosis of pneumothorax and pleural effusion after noncardiac thoracic surgery. Patients received 2 ultrasound scans, the first on the day of surgery and the second before chest tube removal. A total of 297 patients underwent 545 examinations; 336 ultrasound scans (61.6%) showed neither pneumothorax nor pleural effusion. Pneumothorax was detected on 69 roentgenograms and 51 ultrasound scans. Both modalities showed positive results in 32 cases and negative results in 395 cases (Cohen's κ, 53.4%). Ultrasound missed 37 clinically irrelevant pneumothoraces. Roentgenograms missed 19 pneumothoraces; 15 of themwere clinically irrelevant. Sensitivity and specificity were 59.4% and 95.9% in the first examination and 50.0% and 94.8% in the second examination, respectively. Pleural effusion was detected on 169 roentgenograms and117 ultrasound scans. Both modalities showed positiveresults in 88 cases and negative results in 336 cases (Cohen's κ, 49.6%). Ultrasound scans missed 81 pleural effusions; except for 5 cases, the clinical decisions would not have changed. Roentgenograms missed 29 clinically irrelevant pleural effusions. Sensitivity and specificity were 44.4% and 92.6% in the first examination and 60.9% and 91.3% in the second examination, respectively. Given high specificities, a large share of results without pneumothorax and pleural effusion, and mismatch analysis, we could reduce the number of roentgenograms by 61.6% by using ultrasound as a primary imaging modality.

Robotic video-assisted thoracoscopic surgery using conventional thoracoscopic access

Video assisted thoracic surgery (VATS) has been widely used and confirmed to be effective and less invasive compared with conventional open surgery. Robotic video-assisted thoracic surgery (R-VATS) is VATSusing a surgeon-controlled robotic system. R-VATS has been increasingly performed worldwide but not in Vietnam. Wehave started implementing r-VATS since July 2018, using conventional thoracoscopic accesses (trocars) and reported our initial results after 18 months of implementation with 116 cases. 57 cases of lobectomy, 9 cases of wedge resection,19 cases of thymectomy, 28 cases of mediastinal tumour resection, 1 case of esophagectomy, 1 case of oesophageal leiomyoma resection, and 1 case of diaphragm plication. 110 cases had good outcomes with no complications, 5 cases suffered from haemothorax that lasted for more than 5 days. Onepatient died after 35 days due to pneumonia. The operation time was comparable to that ofc- VATS. Average time to chest tube removal was 2 days. Time from surgery to discharge was comparable to that ofc-VATS.

Case 287.

History A 60-year-old woman was diagnosed with a new right upper lobe stage I lung adenocarcinoma and underwent video-assisted thoracoscopic surgery (VATS) for right upper lobectomy. Her postoperative course was complicated by a large pneumothorax after chest tube removal on postoperative day 3. This was managed with repeat right-sided chest tube placement on the same day. The second chest tube was removed on postoperative day 8 without complications. A 2-week postoperative clinic visit was unremarkable. Postoperative chest radiographs on postoperative days 1, 3, and 8 (Fig 1a-1c) are provided. Subsequently, chest CT scanning was performed as part of routine 6-month postsurgical lung cancer surveillance follow-up (Figs 2, 3). The patient had no clinical complaints at routine follow-up. Physical examination revealed well-healed VATS scars in the chest wall. Laboratory results were within normal limits, including a normal white blood cell count of 6400/μL. Her surgical history included prior left upper lobectomy for remote left upper lobe stage IIIA adenocarcinoma and prior bilateral breast implantation for cosmesis. On the basis of chest CT findings, the patient was transferred from an outside institution.

Spontaneous ventilation video-assisted thoracic surgery for mediastinal tumor resection in patients with pulmonary function deficiency.

BackgroundWhether non-intubated spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) is a safe procedure remains controversial for mediastinal tumor patients with impaired lung function. Herein, we assessed feasibility of SV-VATS in lung function deficiency patients underwent mediastinal tumor resection.MethodsFrom December 2015 to February 2020, 32 mediastinal tumor patients with impaired lung function (preoperative forced expiratory volume in 1 second <70% of the predicted value) were retrospectively collected. Patients were divided into two groups: SV-VATS group and mechanical ventilation VATS (MV-VATS) group. Intraoperative and postoperative variables were compared between two cohorts.ResultsFifteen patients (46.88%) underwent SV-VATS and 17 patients (53.12%) were performed with MV-VATS. The most common causes of lung function deficiency were smoking (81.25%) and COPD (71.88%). Patients in the SV-VATS group had similar blood loss (20.63 vs. 18.76 mL, P=0.417) with MV-VATS group. The anesthesia time (217.51 vs. 197.76 min; P=0.343) and surgery time (141.23 vs. 132.36 min; P=0.209) were also similar between groups. Five people suffered postoperative complications in each group, in which 1 patient underwent MV-VATS was transferred to intensive care unit (ICU) because of prolonged extubation owing to hypoxia. There was no difference on chest tube removal time (2.6 vs. 2.3 days; P=0.172) or hospital duration (5.03 vs. 4.74 days; P=0.297) in patients underwent SV-VATS and MV-VATS.ConclusionsSV-VATS is safe and provides similar short-term results to MV-VATS for mediastinal tumor resection in patients with limited pulmonary function.

Imprint Cytology of Thoracoscopic Pleural Biopsy Tissue for Early Etiological Diagnosis of Pleural Effusion: A Pilot Study From India.

Thoracoscopic pleural biopsy provides the highest diagnostic yield in both malignant and tubercular pleural effusions. However histopathologic report takes 3 to 5 days to provide the diagnosis, resulting in a delay of further management plans like pleurodesis or chest tube removal. Imprint cytology of biopsy tissue can provide early information about the etiological diagnosis. Thus, we conducted this pilot study in 66 patients of exudative pleural effusions undergoing medical thoracoscopy. One or 2 biopsy pieces obtained during medical thoracoscopy from pleural nodules were used to prepare imprint cytology slides in the thoracoscopy suite. In comparison to thoracoscopic pleural biopsy, the diagnostic yield of imprint cytology of pleural tissue was 92% (49 of 53 cases) in cases of malignant pleural effusion and 75% (9 of 12 cases) in cases of tuberculosis pleural effusions. Imprint cytology provided a definite idea about the type of diagnosis, about 2.5 days before the histopathology results. By providing early etiological diagnosis, it may also decrease the duration of hospital stay and health care expenditure. A large prospective trial has been planned in our center to confirm this hypothesis.

Clinical descriptors of pneumothorax following chest tube removal in paediatric cardiac surgery.

There is limited data describing the characteristics of paediatric post-operative cardiac surgery patients who develop pneumothoraces after chest tube removal. Patient management after chest tube removal is not standardised across paediatric cardiac surgery programmes. The purposes of this study were to describe the frequency of pneumothorax after chest tube removal in paediatric post-operative cardiac surgical patients and to describe the patient and clinical characteristics of those patients who developed a clinically significant pneumothorax requiring intervention. A single-institution retrospective descriptive study (1 January, 2010-31 December, 2018) was utilised to review 11,651 paediatric post-operative cardiac surgical patients from newborn to 18 years old. Twenty-five patients were diagnosed with a pneumothorax by chest radiograph following chest tube removal (0.2%). Of these 25 patients, 15 (1.6%) had a clinically significant pneumothorax and 8 (53%) did not demonstrate a change in baseline clinical status or require an increase in supplemental oxygen, 14 (93%) required an intervention, 9 (60%) were <1 year of age, 4 (27%) had single-ventricle physiology, and 5 (33%) had other non-cardiac anomalies/genetic syndromes. In our cohort of patients, we confirmed the incidence of pneumothorax after chest tube removal is low in paediatric post-operative cardiac surgery patients. This population does not always exhibit changes in clinical status despite having clinically significant pneumothoraces. We suggest the development of criteria, based on clinical characteristics, for patients who are at increased risk of developing a pneumothorax and would require a routine chest radiograph following chest tube removal.

Early postoperative day 0 chest tube removal using a digital drainage device protocol after thoracoscopic major pulmonary resection.

The aim of this study was to assess the safety of early chest tube removal on postoperative day 0 (POD 0) on the basis of a digital drainage device protocol in patients undergoing thoracoscopic major lung resection and its contribution as a component of an enhanced recovery after surgery programme. One hundred consecutive patients who underwent thoracoscopic lobectomy or segmentectomy were submitted to the following criteria for chest tube removal: Air flow ≤20 ml/min for at least 4 h without fluid threshold, except if haemorrhagic or chylous. Two groups were defined according to chest tube removal on POD 0 (G0) or POD ≥1 (G1). Primary outcome was pleural complication and secondary outcomes were cardiopulmonary complication, length of drainage, length of stay (LOS), compliance with opioid-free analgesic protocol and readmission. The follow-up was 90 days from discharge. The chest tube was removed on POD 0 in 45% of patients (G0). None of them required tube reinsertion for pneumothorax and 1 patient was readmitted for a delayed pleural effusion. Among the 55% remaining patients (G1), the median length of drainage was 2 days, including 3 prolonged air leaks (>5 days). G0 and G1 were not different in terms of cardiopulmonary complication and readmission (6.6% vs 9% and 4.4% vs 7.2%, respectively). The median LOS was 1 day in G0 and 2 days in G1. The compliance with opioid-free analgesic protocol was significantly higher (75% vs 45%, P = 0.004) in G0 compared to G1. Early POD 0 chest tube removal after thoracoscopic major pulmonary resection is safe in selected patients on the basis of a digital drainage device protocol. Also, it may contribute, by reducing early postoperative pain, to enhance postoperative recovery as part of an advanced enhanced recovery after surgery programme.

Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery

The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery. Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters. Quaternary children's hospital, university setting. The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass. Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines. Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications. Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.

Chest Tube Removal: Efficacy of Cold Application and Breathing Exercise on Pain and Anxiety Level

Context: Post-cardiothoracic surgical chest tube removal (CTR) is considered a painful technique and one of the most painful patients' experiences in the intensive care unit. Painkillers are the most prevalent method to relieve the pain, but the patient may not respond well and achieved complete relaxation. Regardless of scientific advances, no efficient action is possessed to decrease pain and anxiety because of it.&#x0D; Aim: This study aimed to investigate the efficacy of cold application and breathing exercises on pain and anxiety levels following chest tube removal.&#x0D; Methods: A quasi-experimental design (one group pre/post-test) was utilized to achieve the aim. This study was conducted in the Intensive Care Unit at the Cardio-Thoracic Academy Affiliated to Ain Shams University Hospital, Cairo. A Purposive sample included 60 patients undergoing cardiothoracic surgical procedures and having at least two chest tubes in place. Data were collected using three tools; a structured interviewing questionnaire, pain intensity assessment visual numeric scale, short-form McGill pain assessment questionnaire, modified comfort scale, and breathing exercise checklist.&#x0D; Results: This study revealed that patients suffer from severe pain before CTR without cold application and breathing exercise (61.7%), or with the application of them (66.7%), the pain level improved during removal as 80% of patients display no pain when using the cold application and breathing exercise that increased to 95% after 10-15 minute of removal compared to 8.3% when cold application and breathing exercise not used. Otherwise, the anxiety level decreased during CTR as 58.3% had mild anxiety level with cold application and breathing exercises compared to 38.3% had a very severe anxiety level. Mild anxiety level increased to 91.7% after 10-15 minutes of CTR compared to 16.7 % when CTR without application.&#x0D; Conclusion: Cold application and breathing exercises are useful for reducing patients' pain and anxiety levels associated with chest tube removal after cardiothoracic surgery. Encouraging critical care nurses to use cold application and breathing exercises as a non-pharmacological pain relief technique during chest tube removal was highly recommended.

Reasons for extended length of stay following chest tube removal in general thoracic surgical patients.

BackgroundMany patients undergoing general thoracic surgery can be discharged on the same day as chest tube removal, but some are not, leading to increased resource utilization. This study assesses the frequency and duration of extended length of stay (ELOS) after tube removal and identifies risk factors for ELOS.MethodsWe retrospectively reviewed all adult patients undergoing general thoracic surgery at a tertiary referral medical center captured in the Society of Thoracic Surgeons General Thoracic Surgery Database and obtained detailed clinical data on chest tube management from August 2013 to April 2017. Pre-operative demographics, procedures, diagnoses, comorbidities, hospital service category, and lab values were examined to identify risk factors associated with ELOS after chest tube removal using multivariable generalized linear regression models.ResultsOne thousand and four hundred seventy patients had ≥1 chest tubes placed at the time of operation and discharged after chest tube removal: anatomic lung resection (34%), wedge resection (29%), decortication (16%), and other (21%). Fifty-one percent of these patients were male, 81% were white, and the mean age was 59 years (SD: 15 years). One-third of the patients had prior cardiothoracic operations. Twenty-three percent of these patients had ELOS, defined as discharge ≥1 calendar day after chest tube removal with a median additional hospital stay of 3 days (interquartile range, 2–7 days). A multivariable regression model demonstrated that risk factors for ELOS included being admitted to an oncology or transplant service, undergoing decortication procedure, active smoking, and increased disability.ConclusionsPatients with obesity, more severe disability, or actively smoking, undergoing, decortication, admitted to transplant and oncology services were more likely to experience ELOS. These factors should be considered when identifying appropriate patient groups for fast-track algorithms.

Comparison of Videothoracoscopy and Thoracotomy in Surgical Treatment of Pulmonary Hydatid Cyst Disease.

To evaluate the outcomes of videothoracoscopic and open surgeries for pulmonary hydatid cysts. Descriptive study. Department of Thoracic Surgery, Faculty of Medicine, Balıkesir University, Turkey, between May 2015 and March 2020. Patients who underwent surgery for pulmonary hydatid cysts were evaluated retrospectively, for the age, gender, symptoms, cyst size and localisation, preferred surgery, duration of surgery, the extent of the intraoperative bleeding, duration of the chest drainage, hospitalisation time, and postoperative complications. The relationship between the categorical variables was examined with the Chi-square and Fisher's exact tests and the relationship between the non-parametric data and continuous variables with the Mann-Whitney U-test. A total of 60 patients included in the study; 23 underwent videothoracoscopic surgery and 37 had thoracotomy. There were no statistically significant differences between groups as gender, age, location and size of cyst. The videothoracoscopic surgery has superiority to thoracotomy group in terms of lower duration of operation, less perioperative bleeding (p = 0.005), early chest tube removal and lower hospitalisation time (both p <0.001). But there were no statistical difference between groups in complication rates (p = 0.340). Videothoracoscopic removal of pulmonary hydatid cyst is a safe and advantageous procedure comparing to thoracotomy. There is a need for prospective studies with a larger sample size. Key Words: Hydatid cyst, Thoracoscopic surgery, Thoracotomy, VATS.

Feasibility of early removal of chest tube in the operating room for spontaneous pneumothorax: A prospective randomized controlled study

Background/ObjectiveChest drainage tube after surgery causes pain and prolonged length of hospital stay. Especially, young patients tend to experience greater postoperative pain than elderly patients. Therefore, we needed to discuss the indication of chest tube placement. The purpose of this study was to demonstrate the safety and advantages of post-operative management without drainage tube placement, by comparing cases with and without drainage tube placement. MethodsPatients who underwent bullectomy for spontaneous pneumothorax were enrolled in this prospective randomized controlled study and randomized into two groups: group with a post-operative chest tube and group without a chest tube. Surgery and post-operative management were performed according to our protocol. ResultsAmong the 42 patients, pneumothorax occurred in 1 patient with a chest tube a day after tube removal. Patients without chest tube had significantly lower post-operative pain (P = 0.107∼P < 0.001), despite their reduced use of rescue drugs. The mean length of post-operative hospital stay was 2.5 days in patients with chest tube, which was significantly longer than that of patients without chest tube (1.2 days; P < 0.001). ConclusionsOur patient selection and surgical protocols may be feasible and contribute to post-operative pain control.

1656P Anti-angiogenic therapy induced pneumothorax (AIP) is associated with long-lasting response and survival benefit for paediatric and young adult sarcoma

AIP in sarcoma has been widely noticed as a hard to treat complication, leading to dismal outcomes. Although drug interruption is usually indicated, anecdotal evidence has identified some AIP patients continuing anti-angiogenic therapy (AAT) during AIP as exceptionally durable responders. A total of 131 sarcoma pts were treated with apatinib-containing therapy in our institution. From Sep. 2017, we implemented a non-stop strategy for 28 sarcoma pts with AIP using a multi-disciplinary approach to avoid interrupting AAT. Another 10 AIP pts treated with drug interruption strategy (pts decision or referral from other institution) served as a pragmatic control. AIPs were significantly enriched in young, heavily pre-treated, male patients with lung metastases with cavitary changes. AIPs with non-stop strategy were associated with drastically longer progression-free survival (PFS) (12.0 mo), compared to those without AIP (6 mo) or AIP with drug interruption (4.0 mo) (P=0.003), with the best even >3 yr. Such benefit was further translated into pts' overall survival, with a borderline statistical significance (AIP group 23.3 mo vs control 16.9 mo, P=0.099). There were no deaths directly related to the pneumothorax. Removal of chest tube was achieved in 31 (81%) of the pts, while 4 lived with permanent tubing and 3 died from complications of long-term tubing. Interestingly, cavitary lesions presented in all ages (rather than only in young pts) and the concurrence of AIP and cavitation accounted for only 54% of the cases, suggesting additional contributing factors of AIPs. To this end, 21 common SNPs were screened, and VEGFR2 A-to-G polymorphism (rs2071559) remained as the only biomarker for both the therapeutic efficacy and the risk of AIPs. RNA-seq data of 21 osteosarcomas suggest a different phenotype of the vasculature between the AA versus the A-to-G genotype. To test the generalizability of our result, we reviewed 31 previously published trials and found that there is a general correlation of the AIP incidence with the treatment efficacy, in terms of overall response rate (ORR) (r=0.64, P<0.001) and PFS (r=0.44,P=0.014), further supporting that AIP might be an efficacy related AE deserving attentions. Our multidisciplinary strategies assure sarcoma pts with AIP to remarkably benefit from AAT as durable responders. Further investigation of the germline biomarker of AIP for risk stratification and individualized regimens is warranted.

Lymphatic imaging and intervention for chylothorax following thoracic aortic surgery

Reports on lymphatic intervention for chylothorax complicating thoracic aortic surgery are limited. We aimed to evaluate technical and clinical outcomes of lymphangiography and thoracic duct embolization (TDE) for chylothorax complicating thoracic aortic surgery.Nine patients (mean age, 38.9 years) who underwent chylothorax interventions after thoracic aortic surgery (aorta replacement [n = 7] with [n = 2] or without [n = 5] lung resection, and vascular ring repair [n = 2]) were reviewed retrospectively. Magnetic resonance (MR) lymphangiograms were obtained in 5 patients. The median interval between surgery and conventional lymphangiography was 9 days (range, 4–28 days). TDE clinical success was defined as lymphatic leakage resolution with chest tube removal within 2 weeks.MR lymphangiograms revealed contrast leakage from the thoracic duct (n = 4) or no definite leakage (n = 1), which correlated well with conventional lymphangiogram findings. The technical success rate of conventional lymphangiography was 88.9% (8/9); 8 patients showed contrast leakage, while the patient without definite leakage on MR lymphangiography had small inguinal lymph nodes, and thoracic duct visualization by conventional lymphangiography failed. The technical success rates of antegrade and retrograde TDE via pleural access were 75% (6/8) and 100% (3/3), respectively. Clinical outcomes after embolization, as judged by the tube-removal day, were similar between low- (<500 mL/day) and high-output (≥500 mL/day) chylothorax patients. The drainage amount decreased significantly after lymphangiography/TDE, from 710.0 mL/day to 109.7 mL/day (p < .05). The clinical success rate of TDE was 87.8% (7/8).Conventional lymphangiography and TDE yielded high technical success rates and demonstrated encouraging clinical outcomes for chylothorax complicating thoracic aortic surgery.

Serratus anterior plane block for video-assisted thoracoscopic surgery: A meta-analysis of randomised controlled trials.

The serratus anterior plane block (SAPb) is a promising interfascial plane technique able to provide profound thoracic analgesia. As only a few studies with quite small patient samples are presently available, the analgesic efficacy of adding SAPb to general anaesthesia in video-assisted thoracoscopic surgery (VATS), compared with general anaesthesia only, remains unclear. Our primary aim was to assess the analgesic efficacy of SAPb for VATS peri-operative pain control. The secondary aims were to evaluate differences in postoperative opioid use, intra-operative hypotension, postoperative side-effects and complications, time to chest tube removal, length of hospital stay. Systematic review of randomised controlled trials (RCTs) with meta-analyses.DATA SOURCES PubMed, Web of Science, Google Scholar and the Cochrane Library, searched up to 6 December 2019.ELIGIBILITY CRITERIA RCTs including adult patients undergoing VATS who received single shot SAPb (cases), compared with general anaesthesia (controls). Seven RCTs, with a total of 489 patients were included. SAPb reduced pain scores peri-operatively, compared with controls: 6 h [mean difference -1.86, 95% confidence interval (CI) -2.35 to -1.37, P < 0.001]; 12 h (mean difference -1.45, 95% CI -1.66 to -1.25, P < 0.001); 24 h (mean difference -0.98, 95% CI -1.40 to -0.56, P < 0.001). SAPb also reduced the use of postoperative opioids (mean difference: -4.81 mg of intravenous morphine equivalent, 95% CI -8.41 to -1.22, P < 0.03) and decreased the incidence of nausea and vomiting (risk ratio 0.53, 95% CI 0.36 to 0.79, P < 0.002). Compared with general anaesthesia only and if no other locoregional techniques are used, SAPb significantly reduces postoperative pain and nausea and vomiting in patients undergoing VATS. Grading of Recommendations Assessment, Development and Evaluation rating are, nonetheless, quite low, due to high heterogeneity. Well designed and properly powered RCTs are necessary to confirm these preliminary findings.

Bubbles-in-the-chamber vs digital screen in chest drainage: A blind analysis of compared postoperative air leaks evaluation

BackgroundChest drainage systems are affected by intra and inter-observer variability and poor sensibility in detecting minimal or apparent air leaks. ObjectivesOvercome intra and inter-observer variability in detecting air leaks. MethodsAfter surgery, a single apical chest tube was connected to the Drentech™ PalmEVO device and air leaks were checked twice a day by observation of both bubbles-in-the-chamber and digital data. ResultsOn a total of 624 observations, disagreement between digital and traditional systems was recorded in 60(9.6%) cases. In 25(21.4%) patients, a disagreement was recorded. Overall, the digital evaluation influenced clinical management in 13(52%). In 10(40%) patients with temporary discordant features, the presence of high pleural fluid output led to a progressive final concordance. ConclusionsDisagreement between traditional and digital systems in checking air leaks is not negligible. Digital systems could give advantages in making an objective assessment of air leaks, standardizing the timing of chest tube removal.

The Safety and Efficacy of Ultrasound-Guided Serratus Anterior Plane Block (SAPB) Combined with Dexmedetomidine for Patients Undergoing Video-Assisted Thoracic Surgery (VATS): A Randomized Controlled Trial.

BackgroundAlthough video-assisted thoracic surgery (VATS) can significantly reduce postoperative pain, the incidence is as high as 30–50%. The purpose of this study was to explore the safety and efficacy of ultrasound-guided serratus anterior plane block (SAPB) combined with dexmedetomidine (Dex) for patients undergoing VATS.MethodsEighty patients were randomized into two groups (20 mL 0.5% ropivacaine plus 0.5 µg/kg or 1 µg/kg Dex). Primary outcome was the visual analog scale of pain while coughing (VASc) score at 24 h after surgery. Secondary outcomes included hemodynamics, sufentanil consumption, number of patients needing rescue analgesia, time to first rescue analgesic, total dose of rescue analgesic, satisfaction scores of patients and surgeons, time of chest tube removal, length of hospital stay, adverse effects, the prevalence of chronic pain and quality of life.ResultsCompared with D1 group, visual analog scale of pain at rest (VASr) was significantly lower during the first 24 h after surgery, while VASc was significantly lower during the first 48 h after surgery (P<0.05). Mean arterial pressure was significantly decreased from T2 to T8, and heart rate was significantly decreased from T2 to T7 in the D2 group (P<0.05). Consumption of sevoflurane, remifentanil, DEX and the recovery time were significantly reduced in the D2 group (P <0.05). Consumption of sufentanil 8–72 h after surgery was significantly lower in the D2 group (P<0.05). Additionally, the number of patients who required rescue analgesia, the time to the first dose of rescue analgesia, and the total dose of rescue analgesia was significantly lower in the D2 group (P<0.05).ConclusionThe results of this study show that 1 µg/kg DEX is a beneficial adjuvant to ropivacaine for single-injection SAPB in VATS patients while stable hemodynamics were maintained.

Treatment of Chylothorax after Lung Resection: Indications, Timing, and Outcomes.

Chylothorax following pulmonary resection and lymphadenectomy for cancer is a potential severe complication in thoracic surgery. In the present study, we investigated the efficacy of the nonsurgical approach as well as the need for reoperation after conservative approach failure. Chylothorax was diagnosed when chylous leakage from the chest drainage was observed and confirmed by the presence of triglycerides in the pleural fluid. We initially treated all the patients conservatively with complete oral intake cessation and total parenteral nutrition; if drainage output remained more than 800 mL/d after the first 5 days or major pleural effusion was observed at chest X-ray after chest tube removal, surgical treatment of chylothorax was indicated. Between January 1998 and December 2018, 5,072 patients underwent standard anatomical resection and mediastinal lymph node dissection for cancer at our institution. Among them, 30 patients (0.6%) developed chylothorax: 20 patients were effectively treated only by nil per os and low-fat diet, while 10 patients (33.3%) required surgical treatment. Mean age was 63 years; there were 24 male patients (80%); right-sided chylothorax was more frequent than left-sided chylothorax (22 vs. 8, respectively) although not statistically significant (p = 0.38); the only factor that seems to influence the need for reoperation is chylothorax flow rate during conservative treatment (p = 0.06). Conservative treatment is effective in the case of low flow-rate chylothorax (< 800 mL/d); in the case of a higher flow rate, surgical exploration is needed and thoracic duct ligation-with or without lymphatic sites clipping-provides definitive lymphostasis.

Analgesic Effectiveness of Perioperative Ultrasound-Guided Serratus Anterior Plane Block Combined with General Anesthesia in Patients Undergoing Video-Assisted Thoracoscopic Surgery: A Systematic Review and Meta-analysis.

To investigate whether perioperative ultrasound-guided serratus anterior plane block (SAPB) combined with general anesthesia is more effective and safer than current analgesic techniques for postoperative analgesia after video-assisted thoracoscopic surgery (VATS). PubMed, the Cochrane Library, and EMBASE were searched for clinical trials published up to July 31, 2019. Outcomes, including operative duration, postoperative pain scores, postoperative analgesia use, patient satisfaction with analgesia, time to chest tube removal, length of stay, and adverse effects were analyzed. Four clinical trials, including 262 patients, met inclusion criteria. Ultrasound-guided SAPB reduced pain scores at zero, 15, 30, 45, and 60 minutes in the postoperative anesthesia care unit (all P < 0.05) and at one, two, six, 12, and 24 hours in the ward (all P < 0.001). Additionally, postoperatively, morphine consumption at 15 and 30 minutes, overall morphine consumption, and total consumption (morphine plus tramadol) were significantly lower in the SAPB cohort (P < 0.05). Similarly, postoperative tramadol consumption at one, two, six, 12, and 24 hours was also lower in this cohort (all P < 0.05). The postoperative consumption of fentanyl, tramadol, and total morphine in patient-controlled analgesia (PCA) at 24 hours was significantly reduced (P < 0.05). Moreover, SAPB provided better patient satisfaction with analgesia (P = 0.0038). However, no statistically significant difference was found in duration of operation, time to chest tube removal, length of stay, or side effects (all P > 0.05). Perioperative ultrasound-guided SAPB combined with general anesthesia provided more effective postoperative analgesia after VATS. However, no significant advantage was found regarding side effects.

Growth of cardiac infants with post-surgical chylothorax can be supported using modified fat breast milk with proactive nutrient-enrichment and advancement feeding protocols; an open-label trial.

Previously we showed that modified fat breast milk (MFBM) facilitated resolution of post-surgical chylothorax in cardiac infants, but their weight-for-age and length-for-age z-scores declined over the ≥6-week treatment duration. Our aim was to evaluate the growth of infants diagnosed with post-surgical chylothorax and fed according to one of two proactive feeding protocols using MFBM or a high medium triglyceride (MCT)-containing formula (standard of care). In this open-label trial, infants who were receiving >50% of their enteral feeds as breast milk prior to chylothorax diagnosis were randomized to receive their enteral feeds according to one of two proactive MFBM protocols: Target Fortification (n=8), where the protein concentration of defatted breast milk was measured weekly and multi- and single-nutrient modulars were added to provide 3.5g/kg/day of protein; or Higher Initial Concentration (n=8), where defatted breast milk was initially fortified to an energy and nutrient level higher than that of unmodified breast milk (80kcal/100ml; 2.2g/100ml protein). A third nonrandomized group of infants (n=8) received high MCT formula (68kcal/100ml; 2.3g/100ml protein). The intervention lasted for a minimum of 6-weeks after chest tube removal and continued after discharge. Weekly weight, length and head circumference (HC) measurements were completed. At enrolment, there was no statistically significant differences in mean (±SD) weight-for-age (-1.6±0.9, n=24), length-for-age (-1.3±0.8), or HC-for-age (-0.9±1.0) z-scores among groups. Changes in mean weight- (-0.3±0.9, n=23), length- (0.1±0.6) and HC-for-age (0.2±0.6) z-scores did not differ among groups over the treatment period. There was no difference in duration or volume of chest tube drainage across groups. Use of proactive MFBM feeding protocols both resolve chylothorax and support growth in infants following cardiothoracic surgery. ClinicalTrials.gov (NCT02577419).