Small-bore Drains Research Articles

Effectiveness and safety of CT-guided drainage of abdominal abscesses with small and extra-small-bore drains: a single-centre observational study.

Computed tomography (CT)-guided percutaneous drainage is an established method for the treatment of abdominal abscesses. The purpose of this study is to evaluate the effectiveness and safety of drainage of abdominal abscesses with small-bore (6F and 9F) drains. The analysis of a prospectively maintained database included 135 consecutive patients from a single centre with abdominal or pelvic abscesses, who underwent CT-guided drainage. Procedures were performed using a one-step trocar technique with 6F (40 procedures) or 9F (95 procedures) catheters. Technical success was defined as insertion of the drain into the abscess cavity and aspiration of the fluid sample. Clinical success was defined as resolution of infection without surgical intervention or upsizing of the drain. The mean size of abscesses was 77.0 ± 28.8 mm (32-220 mm). Thick fluid was aspirated from 129 collections; 6 collections contained thin fluid. Technical success was achieved in 100% of procedures. Clinical success was achieved in 94.8% of patients. Surgical drainage was necessary in 3.7% of patients and upsizing in 1.5% of patients. Complications of Clavien-Dindo grade III were noted in 2.2% of patients without grade IV or V adverse events. The mean radiation dose in terms of Dose Length Product was 617 ± 467 mGy x cm. The mean procedure time was 28.0 ± 11.3 min. CT-guided drainage of abdominal abscesses with small- and very small-bore drains is usually sufficient to obtain clinical success with a low complication rate in the case of thick fluid collections.

A randomized controlled trial: Comparison of 14 and 24 French thoracic drainage after minimally invasive lobectomy – MZ 14-24 study

BackgroundThe optimal placement of a chest drain after video-assisted minimally invasive lobectomy should facilitate the aspiration of air and drainage of fluid. Typically, a conventional 24Ch polyvinyl chloride chest drain is used for this purpose. However, there is currently no scientific literature available on the impact of drain diameter on postoperative outcomes following anatomical lung resection. MethodsThis is a prospective, randomized, phase-1 trial that will include 40 patients, which will be randomly assigned into two groups. Group 1 will receive a 24 French chest drain according to current standards, while group 2 will receive a 14 French drain. Primary endpoint of the trial is the incidence of postoperative drainage-related complications, such as obstruction, dislocation, pleural effusion, and reintervention. Secondary endpoints are postoperative pain, chest drainage duration, incidence of complications, and hospital length of stay. The study aims to determine the number of subjects needed to achieve a sufficient test power of 0.8 for a non-inferiority study. DiscussionThoracic surgery is becoming more and more minimally invasive. One of the remaining unresolved problems is postoperative pain, with the intercostal drain being one of the main contributing factors. Previous data from other studies suggest that the use of small-bore drains can reduce pain and speed up recovery without an increase in drain-related complications. However, no studies have been conducted on patients undergoing anatomic lung resections to date. The initial step in transitioning from larger to smaller drains is to establish the safety of this approach, which is the primary objective of this trial.Trial registration: The study has been registered in the German Clinical Trials Register.Registration number: DRKS00029982.URL: https://drks.de/search/de/trial/DRKS00029982.

1086 Improving the Use of Chest Drains in Trauma - Small but Perfectly Formed

Abstract Aim The Western Trauma Association (WTA) advocates using small-bore chest drains (e.g., 14Fr) in haemodynamically normal trauma patients for management of small Haemothoraxes (HTX) or Pneumothoraxes (PTX). This quality improvement project aimed to assess implementation of this guidance. Method We compared the use and outcomes of small-bore chest drains for management of HTX or PTX before (Cohort 1) and after (Cohort 2) adoption of WTA recommendations in a District General Hospital in London. We included all patients admitted under the General Surgeons with rib fractures. Results All patients were admitted with blunt chest injuries. Cohort 1: 60 patients [36 males, mean age 72 years (range 31-96)] admitted from May–December 2021. Cohort 2: 78 patients [42 males, mean age 73 years (range 23-102)] admitted from May–December 2022. In cohort 1, 10 patients (16%) required chest drains, all were surgically inserted large bore drains (median size 28 Fr) there were no peri-procedural complications. In cohort 2, 11 patients (14%) required chest drains; 5 were surgically placed large bore drains (median size 28 Fr) and 6 were small-bore drains inserted by Seldinger technique (median size 18Fr). Two large-bore drains had periprocedural complications and both required re-insertion. The mean age was 60 years. In the small-bore group, there were no peri-procedural complications, no drains occluded and the mean age was 75 years. Conclusions After the implementation of this policy, small-bore drain use increased and appeared safe. This audit supports recent literature suggesting small-bore drains are as effective as larger bore and better tolerated.

FTP1.13 Improving the use of chest drains in trauma - Small but perfectly formed

Abstract Aims The Western Trauma Association (WTA) advocates using small-bore chest drains (e.g. 14Fr) in haemodynamically normal trauma patients for management of small Haemothoraxes (HTX) or Pneumothoraxes (PTX). This quality improvement project aimed to assess implementation of this guidance. Method We compared the use and outcomes of small-bore chest drains for management of HTX or PTX before (Cohort 1) and after (Cohort 2) adoption of WTA recommendations in a District General Hospital in London. We included all patients admitted under the General Surgeons with rib fractures. Results All patients were admitted with blunt chest injuries. Cohort 1: 60 patients [36 males, mean age 72 years (range 31-96)] admitted from May–December 2021. Cohort 2: 77 patients [42 males, mean age 73 years (range 23-102)] admitted from May–December 2022. In cohort 1, 10 patients (16%) required chest drains, all were surgically inserted large-bore drains (median size 28 Fr) there were no peri-procedural complications. In cohort 2, 11 patients (14%) required chest drains; 5 were surgically placed large bore drains (median size 28 Fr) and 6 were small-bore drains inserted by Seldinger technique (median size 18Fr). Two large-bore drains had periprocedural complications and both required re-insertion. The mean age was 60 years. In the small-bore group there were no peri-procedural complications, no drains occluded and the mean age was 75 years. Conclusion After the implementation of this policy, small-bore drain use increased and appeared safe. This audit supports recent literature suggesting small-bore drains are as effective as larger bore and better tolerated.

Clinico-radiological profile and outcome of patients undergoing intercostal tube drainage in a tertiary care hospital in West Bengal, India

Introduction: Evacuation of empyema which was first performed centuries ago, marked the beginning of thoracic drainage. The subsequent acquisition of a greater knowledge of the anatomy, physiology, and pathology of the pleural space directed the design of thoracic catheters and drainage systems and the development of the methods by which they are used. Thoracic drainage systems are designed to remove air and liquids from the pleural space or mediastinum, which collect there as a result of injury, disease, or surgical procedures. Method: A total of 100 patients who underwent intercostal tube drainage due to various etiologies are followed up for 3 months in the study Results: In this study it was observed that pneumothorax (67%) as the most common indication for chest drain insertion followed by hydro-pneumothorax. During this period 100 patients of different pathologies related to chest underwent chest intubations. Amongst them 88(88%) were male and 12(12%) were female. Subcutaneous emphysema was found to be the most common complication followed by ICD tube blockage. Among the study population 95% patients were successfully treated & unsuccessful outcome was only 5%. Conclusion: Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general. Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains.

Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists

Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothoraces and malignant effusions (for which an immediate pleurodesis is planned). Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains. Chest tube insertion should be guided by imaging, either bedside ultrasonography or, less commonly, computed tomography. The so-called trocar technique must be avoided. Instead, blunt dissection (for tubes >24F) or the Seldinger technique should be used. All chest tubes are connected to a drainage system device: flutter valve, underwater seal, electronic systems or, for indwelling pleural catheters (IPC), vacuum bottles. The classic, three-bottle drainage system requires either (external) wall suction or gravity (“water seal”) drainage (the former not being routinely recommended unless the latter is not effective). The optimal timing for tube removal is still a matter of controversy; however, the use of digital drainage systems facilitates informed and prudent decision-making in that area. A drain-clamping test before tube withdrawal is generally not advocated. Pain, drain blockage and accidental dislodgment are common complications of small-bore drains; the most dreaded complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema. IPC represent a first-line palliative therapy of malignant pleural effusions in many centers. The optimal frequency of drainage, for IPC, has not been formally agreed upon or otherwise officially established.

When size matters: changing opinion in the management of pleural space-the rise of small-bore pleural catheters.

Tube thoracostomy is usually the first step to treat several thoracic/pleural conditions such as pneumothorax, pleural effusions, haemothorax, haemo-pneumothorax and empyema. Today, a wide range of drains is available, ranging from small to large bore ones. Indications for an appropriate selection remains yet matter of debate, especially regarding the use of small bore catheters. Through this paper, we aimed to retrace the improvements of drains through the years and to review the current clinical indications for chest drain placement in pleural/thoracic diseases, comparing the effectiveness of small-bore drains vs. large-bore ones.

Retained foreign body following pleural drainage with a small-bore catheter

Small-bore radiopaque drains can be used to drain pleural effusions. They offer reliable drainage of simple pleural effusions and provide a safe, less-invasive, more comfortable alternative to the standard tube thoracostomy. Importantly, removal of such drains does not require purse-string sutures and hence can be removed without assistance. We report here the cautionary tale of a retained foreign body related to drainage of a pleural effusion with a Pleurocath in a patient following cardiac surgery to raise awareness of this potential complication. Emphasized is the need for all staff to be familiar with the normal appearance of equipment being utilized in the ward and to report when incomplete removal of drain equipment is suspected. In addition, amendments to insertion techniques for such small-bore drains are proposed to avoid similar undue complications.

Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces

To compare treatment success of large- and small-bore chest drains in the treatment of spontaneous pneumothoraces the case-notes were reviewed of those admitted to our hospital with a total of 73 pneumothoraces and who were treated by trainee doctors of varying experience. Both a large- and a small-bore intercostal tube drain system were in use during the two-year period reviewed. Similar pneumothorax profile and numbers treated with both drains were recorded, resulting in a similar drain time and numbers of successful and failed re-expansion of pneumothoraces. Successful pneumothorax resolution was the same for both drain types and the negligible tube drain complications observed with the small-bore drain reflected previously reported experiences. However the large-bore drain was associated with a high complication rate (32%) with more infectious complications (24%). The small-bore drain was prone to displacement (21%). There was generally no evidence of an increased failure and morbidity, reflecting poorer expertise, in the non-specialist trainees managing the pneumothoraces. A practical finding however was that in those large pneumothoraces where re-expansion failed, the tip of the drain had not been sited at the apex of the pleural cavity irrespective of the drain type inserted.

TS10 RARE CASE OF RETAINED FOREIGN BODY FOLLOWING PLEURAL DRAINAGE WITH A PIGTAIL CATHETER

Small-bore radio-opaque drains such as Bonanno's catheter, pigtail catheters and Pleurocath(r) (PRODiMED, France) can be used to drain pleural effusions. As an alternative to standard tube thoracostomy, they can provide an effective, safe, less invasive and more comfortable option [1, 2] and the principles behind their insertion can be easily taught to junior physicians without the need for radiological guidance. Their removal does not require any purse string sutures and hence they can be removed by a single staff member without the need for additional assistance. We report here the cautionary tale of a retained foreign body related to drainage of a pleural effusion with a Pleurocath(r) in a patient following cardiac surgery, in order to raise awareness of this potential complication. Emphasised is, the need for all staff to be familiar with the normal appearance of equipment being utilised in the ward and to report when incomplete removal of drain equipment is suspected. In addition, amendments to insertion techniques for such small-bore drains are proposed in order to avoid similar undue complications.

Comparative Analysis of the Bonanno Catheter and Tube Thorocostomy in Effective Aspiration of Pleural Effusion

In our earlier report, we suggested the Bonanno catheter (a 14-gauge suprapubic catheter) as a less traumatic but equally effective alternative for drainage of a variety of fluid collections, including pleural effusion. This study aims to evaluate the efficacy of the Bonanno catheter compared with closed-tube thoracostomy in draining pleural effusion in 38 patients following routine cardiac surgery between 2003 and 2004. Twenty patients were managed using the Bonanno catheter and 18 were treated with standard tube thoracostomy. Data were collected retrospectively and statistical analysis was performed using the SPSS software. P < .05 was considered significant. There were 20 (53%) male and 18 (47%) female patients with a mean age of 63.5 years (range, 31-83 years). Significant differences were observed with regards to the amount of lignocaine administered locally, intra-procedure pain score, post-procedure pain score after 15 minutes, and amount of analgesia used on a regular basis (P < .05 in each case). Statistically, significant differences were also noted during 2 to 3 weeks follow-up between the 2 groups with regards to pain score. In the the tube thoracostomy group, 22.2% developed infection of the procedure site, requiring antibiotic treatment, whereas no infection was reported in the Bonanno group (P < .001). This study provided evidence that smallbore drains such as the Bonanno catheter are safe and better tolerated than standard chest drains. This is consistent with the British Thoracic Society guidelines that strongly recommend small-bore drains for the drainage of pleural effusions as they are more comfortable than larger-bore tubes.

Pleural drain malposition

Sir: Small-bore chest drains with removable introducer needle (such as the 8-Fr Pleurocath®, Plastimed, Saint-Leu-La Foret, France) can be used to drain liquid pleural effusions or pneumothorax [1]. We report a case of severe vascular injury due to Pleurocath® malposition, with the goal of raising awareness among physicians about this life-threatening complication, and discuss methods for a safer procedure. A 67-year-old man with a recent history of trauma and hemorrhagic shock followed by postanoxic encephalopathy was admitted to a general medicine ward for investigation of left hydropneumothorax. Thoracic computed tomography confirmed the left hydropneumothorax. A Pleurocath® was inserted on the left mid-axillary line with the patient in the 45° semi-recumbent position. Blood issued through the distal end of the catheter immediately after insertion but was mistakenly taken as evidence of hemothorax. Hemorrhagic shock occurred within a few minutes and the catheter was clamped. The patient was transferred to the intensive care unit. Catheter malposition was suspected. A chest radiograph showed the tip of the catheter in the superior mediastinum, but without an accurate location. Fluid resuscitation and blood transfusion were started. Thoracic computed tomography (CT) with contrast enhancement showed that the catheter ran through the left ventricle, ascending aorta (Fig. 1), and right carotid. The patient was immediately transferred to a cardiothoracic surgery center, where the catheter was removed through a left thoracotomy. The patient was discharged from the unit 3 weeks later. Use of small-bore catheters may reduce morbidity compared with chest tubes [2]. Several cases of cardiac puncture have been reported with larger-bore drains over rigid inner trocars (e.g., Mallinckrodt®) [3] and, more rarely, with small-bore drains (e.g., Pleurocath®). However, our case report shows that small-bore catheters may be associated with life-threatening complications. In our patient, the main factors causing cardiac injury were probably insertion of the catheter low in the left chest wall, through the sixth intercostal space and the small size of the effusion. The published guidelines of the British Thoracic Society [2] recommend insertion in the “safe triangle” bordered by the anterior border of the latissimus dorsi, the lateral border of

Chest Drains: Does Size Matter?: Review

Hippocrates first advocated pleural drainage 2400 years ago when he described the use of incision, cautery and metal tubes to treat empyema [1]. The technique became widely used during the influenza epidemic of 1917 to drain post-pneumonic empyema [2]. In recent years, large-bore drains have been the mainstay of treatment for percutaneous drainage of pleural collections and they remain in use for post-surgical thoracic drainage. Indications for tube placement within the chest include pneumothorax, benign and malignant pleural effusion, parapneumonic effusion and empyema, and haemothorax. Traditional surgical teaching dictates that viscous fluid collections require large tubes for successful drainage [3,4]. Recent publications suggest that a variety of pleural collections can be adequately drained using small-bore catheters, often inserted under imaging guidance, avoiding the complications associated with the ‘blind’ insertion of large-bore chest tubes. It is likely that the evidence supporting the use of small-bore drains within the abdomen and pelvis may be applicable in the chest. It is also possible, but perhaps less likely, that dissemination of this evidence may end the not infrequent assertion by clinicians that patients ‘would have been better treated with a bigger drain’.