Chest Tube Research Articles

Needle aspiration versus tube thoracostomy in patients with symptomatic primary spontaneous pneumothorax: an updated meta-analysis of randomized controlled trials.

Primary spontaneous pneumothorax (PSP) is an important disease commonly seen in young males. While incidentally diagnosed cases can be managed conservatively, symptomatic patients often necessitate intervention. Chest tube placement (tube thoracostomy) is commonly used, at least in the USA as a primary treatment modality, which requires hospitalization. On the other hand, needle aspiration (NA) has been widely adopted due to simplicity and reported efficacy and safety. No consensus is reached regarding superiority and/or preferred modality, with a lack of guidelines agreement. Therefore, we conducted an updated meta-analysis of randomized controlled trials comparing NA to tube thoracostomy in patients with symptomatic PSP. Prespecified outcomes were immediate success rate, 12-month recurrence rate, post intervention complications rate, and hospital length of stay. We identified and pooled data from six randomized trials, with a total of 759 patients and a median follow up of 12 months. Our analysis showed that NA and tube thoracostomy have similar immediate success rate and 12-month recurrence rate. We also found that NA has less complication rate, need for surgical intervention, and less hospital stays. In conclusion, our review showed that in symptomatic patients with PSP, NA is as effective as tube thoracostomy regarding immediate success rate and 12-month recurrence rate, with the added benefit of less complications rate and need for surgical intervention.

Improvements in Efficiency and Resident Satisfaction Following the Implementation of a Central Supply Closet

Introduction: In the 1970’s, the idea of burnout began and was defined as emotional exhaustion, depersonalization, and low sense of personal accomplishment (1). Recently, there has been a push by graduate medical education to counter resident burnout, as demonstrated by resident wellness initiatives becoming a requirement for residency programs in the United States (2). At our institution, a source of burnout was the time it took to gather supplies for critical bedside procedures, which was addressed by instituting a central supply closet. Methods: A checklist was made of the supplies needed for four common bedside procedures: central venous access, arterial line placement, thoracostomy tube placement, and incision and drainage. 9 surgery residents were individually timed to locate the equipment required for each individual procedure with the supply closet and without. A survey was used to evaluate resident satisfaction in the number of locations to search, timeliness, and ability to provide quality patient care before and after the supply closet. This survey was done on a scale of 1 to 5, with 1 being very dissatisfied, and 5 being very satisfied. Paired t-tests were used for data analysis; p<0.05 was considered statistically significant. Results: For central line supplies, the average times were 542 seconds (s) without the closet, and 211s with the closet (p=0.0041), arterial line supplies took 570s without and 178s with (p=0.0114), thoracostomy tube supplies took 590s without, and 213s with (p=0.0017), and incision and drainage supplies took 518s without, and 239s with the closet (p=0.0066). Average resident satisfaction for the number of locations to search for supplies went from 1.5 to 4.8 with the closet, length of time to gather supplies went from 1.3 to 4.9 with the closet, and ability to provide quality patient care went from 1.4 to 4.8 (all p<0.0001). Conclusions: The implementation of a supply closet with easy access to supplies allowed for improved speed in completing bedside procedures, leading to expedited patient care, improved resident satisfaction and well-being, and decreasing a source of surgery resident burnout.

Nefopam as a multimodal analgesia in thoracoscopic surgery: a randomized controlled trial.

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure. However, some patients still experience severe pain after VATS. Pain after VATS can disturb deep breathing and coughing, and can increase postoperative pulmonary complications. Therefore, multidisciplinary pain management is emphasized for enhanced recovery after VATS. Nefopam is a centrally-acting, non-opioid, non-steroidal analgesic drug, and its pain reduction effect in many surgeries has been reported. We sought to determine whether administration of nefopam is effective as multimodal analgesia in VATS. This study enrolled patients aged 19 years or older, and scheduled for elective VATS lobectomy with American Society of Anesthesiologists (ASA) physical class I-III. Forty-six participants were randomly divided into a group receiving nefopam (group N), and a control group (group O) in a 1:1 ratio. The study participants, and the researcher collecting the data were blinded to the group allocation. For the group N, nefopam 20 mg was administered before surgical incision and also at the end of surgery while chest tube was inserted. For the group O, normal saline 100 mL was administered. The primary outcome of this study was the pain score, by verbal numerical rating scale, at rest and upon coughing. Forty-five participants (group N =22, group O =23) were involved in the statistical analysis. Nefopam reduced pain at rest at 0 h [8 (IQR, 5-10) vs. 4 (IQR, 2-7), P=0.01], and at 0-1 h [5 (IQR, 5-8) vs. 3 (IQR, 2-5), P=0.001]. Pain upon coughing decreased with nefopam at 0 h [9 (IQR, 6-10) vs. 6 (IQR, 2-8), P=0.009], 0-1 h [6 (IQR, 5-8) vs. 5 (IQR, 2-6), P=0.001], and at 12-24 h [4 (IQR, 3-7) vs. 3 (IQR, 1-4), P=0.03]. Injection of 20 mg of nefopam before incision and at the end of surgery relieved postoperative pain at 0 h, 1 h at rest and at 0 h, 1 h, 12-24 h with coughing after VATS. Therefore, nefopam can serve as a useful component of multimodal analgesia for pain management after VATS. ClinicalTrials.gov (NCT05173337).

Bronchoscopic management in persistent air leak: a narrative review.

Persistent air leak (PAL) represents a challenging medical condition characterized by prolonged air leak from the lung parenchyma into the pleural cavity, often associated with alveolar-pleural fistula or bronchopleural fistula (BPF). The objective of this narrative review is to explore the causes, clinical implications, and the evolving landscape of bronchoscopic treatment options for PAL. The literature search for this review was conducted using databases such as PubMed/MEDLINE, and Scopus databases. Articles published from inception until 28th August, 2023, focusing on studies that discussed the causes, diagnosis, and management strategies for PAL were included. Keywords included bronchoscopic management, bronchopleural fistula, endobronchial valve, sealant, blood patch pleurodesis, spigot, air leak, PAL, management, comparative study. PAL commonly arises from secondary spontaneous pneumothorax, necrotizing pneumonia, barotrauma induced by mechanical ventilation, chest trauma, or postoperative complications. Understanding the underlying etiology is crucial for tailoring effective management strategies. While conventional intercostal drainage resolves the majority of pneumothorax cases, PAL is diagnosed when the air leak persists beyond 5 to 7 days. Prolonged PAL can lead to worsening pneumothorax, respiratory distress, and increased morbidity. Early identification and intervention are essential to prevent complications. Conservative approaches involve close monitoring and supplemental oxygen therapy. These strategies aim to promote natural healing and resolution of the air leak without invasive interventions. Bronchoscopic techniques, such as endobronchial valves (EBVs), sealants, and autologous blood patch (ABP), have emerged as promising alternatives for refractory PAL. These interventions offer a targeted and minimally invasive approach to seal the fistulous connection, promoting faster recovery and reducing the need for surgical interventions. PAL is a clinical challenge, and their management requires a tailored approach based on the underlying cause and severity. Bronchoscopic interventions have shown efficacy in cases of refractory PAL. Early recognition, multidisciplinary collaboration, and a personalized treatment plan are essential for optimizing outcomes in patients with PAL.

Mini-invasive video thoracoscopic interventions in patients with acute pleural empyema

The use of video thoracoscopic interventions in patients with acute pleural empyema is gaining momentum in modern thoracic surgery. The need of determining the optimal timing of their implementation depending on the duration of the disease and the nature of changes in the parietal and visceral pleura remains open. The nature of changes in the parietal and visceral pleura of 249 patients with acute pleural empyema treated with video thoracoscopic interventions was evaluated. Patients were divided into 5 groups depending on the duration of the disease. It was determined that fibrinous accumulations in acute pleural empyema are replaced by cavity fragmenting formations after 6 weeks from the onset of the disease. The cessation of purulent exudate accumulation and the duration of pleural drainage after thoracoscopy depends on the duration of the disease at the time of thoracoscopy, as evidenced by the duration of pleural drainage in the period up to one month – 8 days from the onset of the disease, up to two months – 15 days, and after 8 weeks of duration – reached 20 days. The main indications for open surgical intervention in this group of patients were the failure of fractional lavage of the empyema cavity due to drainage or the impossibility of adequate rehabilitation according to the presence of a bronchopleural fistula with a duration of its existence of no more than 1 month and no tendency to closure. Inflammatory changes in the pleura in the form of fibrin deposits and cavity fragmentation in pleural empyema increase rapidly enough, the possibility of its effective rehabilitation during thoracoscopy without open surgical interventions is limited to 6 weeks from the onset of the disease. Keywords: acute purulent diseases of the pleura, minimally invasive surgical treatment, sanitation of the pleural cavity, duration of the disease.

When the Pleural Fluid Appears in an Unexpected Color: A Bilothorax Case

Abstract Background: Bilothorax, or cholethorax, is a rare cause of exudative pleural effusion characterized by the presence of bile in the pleural space. Recognizing this condition is essential to prevent severe complications such as empyema and acute respiratory distress syndrome. Case: This report presents a 70-year-old male patient who developed right-sided bilothorax following multiple biliary tract interventions. The patient presented with symptoms of jaundice, fever, and abdominal pain. Clinical and radiological evaluations revealed right-sided pleural effusion, and thoracentesis yielded dark yellow-green fluid. The diagnosis of bilothorax was confirmed by a pleural fluid/serum total bilirubin ratio >1.0. Early intervention was performed using a cystofix to drain the pleural fluid. However, despite all interventions, the sepsis condition could not be controlled, and the patient unfortunately passed away. Discussion: Bilothorax is generally associated with hepatobiliary procedures and is mostly observed on the right side due to anatomical proximity. Diagnosis requires a high index of suspicion, especially in patients with relevant clinical histories and characteristic pleural fluid appearance. Rapid thoracentesis and pleural fluid analysis are crucial for diagnosis. Treatment typically involves pleural drainage and early administration of broad-spectrum antibiotics. Conclusion: Bilothorax is a life-threatening condition requiring urgent diagnosis and intervention. This case highlights the importance of recognizing this rare condition and the necessity for early aggressive management in patients with a history of hepatobiliary procedures.

Thoracoscopic pulmonary resection combined with real-time image-guided percutaneous ablation for multiple pulmonary nodules: a novel surgical approach and literature review.

Due to the widespread use of computed tomography (CT) screening and advances in diagnostic techniques, an increasing number of patients with multiple pulmonary nodules are being detected and pathologically diagnosed as synchronous multiple primary lung cancers (sMPLC). It has become a new challenge to treat multiple pulmonary nodules and obtain a favorable prognosis while minimizing the perioperative risk for patients. The purpose of this study was to summarize the preliminary experience with a hybrid surgery combining pulmonary resection and ablation for the treatment of sMPLC and to discuss the feasibility of this novel procedure with a literature review. This is a retrospective non-randomized controlled study. From January 1, 2022 to July 1, 2023, four patients underwent hybrid surgery combining thoracoscopic pulmonary resection and percutaneous pulmonary ablation for multiple pulmonary nodules. Patients were followed up at 3, 6 and 12 months postoperatively and the last follow-up was on November 30, 2023. Clinical characteristics, perioperative outcomes, pulmonary function recovery and oncologic prognosis were recorded. Meanwhile we did a literature review of studies on hybridized pulmonary surgery for the treatment of multiple pulmonary nodules. All the four patients were female, aged 52 to 70 years, and had no severe cardiopulmonary dysfunction on preoperative examination. Hybrid surgery of simultaneous pulmonary resection and ablation were performed in these patients to treat 2 to 4 pulmonary nodules, assisted by intraoperative real-time guide of C-arm X-ray machine. The operation time was from 155 to 240 minutes, and intraoperative blood loss was from 50 to 200 mL. Postoperative hospital stay was 2 to 7 days, thoracic drainage duration was 2 to 6 days, and pleural drainage volume was 300-1,770 mL. One patient presented with a bronchopleural fistula due to pulmonary ablation; the fistula was identified and sutured during thoracoscopic surgery and the patient recovered well. No postoperative 90-day complications occurred. After 3 months postoperatively, performance status scores for these patients recovered to 80 to 100. No tumor recurrence or metastasis was detected during the follow-up period. Hybrid procedures combining minimally invasive pulmonary resection with ablation are particularly suitable for the simultaneous treatment of sMPLC. Patients had less loss of pulmonary function, fewer perioperative complications, and favorable oncologic prognosis. Hybrid surgery is expected to be a better treatment option for patients with sMPLC.

Comprehensive Analysis of Adverse Events Associated With Hypoglossal Nerve Stimulators: Insights From the MAUDE Database

AbstractObjectiveThis study aims to examine the adverse events associated with hypoglossal nerve stimulator (HNS) implantation for treating obstructive sleep apnea (OSA), drawing data from the Manufacturer and User Facility Device Experience (MAUDE) database. We aim to provide a comprehensive and updated account of these adverse events.Study DesignRetrospective analysis.SettingMAUDE Database review.MethodsA retrospective analysis was performed on the MAUDE database to collect all HNS‐related reports from May 2014 to December 2023. Variables collected included date of event, event description, nature of event, iatrogenic injuries, required interventions, and, if available, root causes. Each event description was analyzed to classify the adverse event, the postevent intervention, and device model number.ResultsOut of 1178 reports fulfilling the inclusion criteria, 1312 adverse events were identified. Common adverse events included infection (24.0%), pain (19.7%), and hematoma/seroma (10.2%). Approximately 83.1% of these adverse events necessitated medical and/or surgical intervention. The most frequent procedures included explantation (29.4%) and device repositioning (15.8%). Pneumothorax was reported in 50 cases, with 41 (82.0%) requiring a chest tube to be inserted. Three adverse events described overstimulation in the setting of magnetic resonance imaging (MRI) despite the implantation of MRI‐compatible second‐generation internal pulse generators.ConclusionWhile HNS implantation has been established as a reliable intervention for OSA in cases of continuous positive airway pressure failure or intolerance, this study highlights several perioperative and postoperative difficulties and complications. Understanding these challenges is essential for refining surgical practices and enhancing patient consent processes, ultimately aiming to improve therapeutic outcomes.

Institutional Guideline May Not Be Enough to Change Practice in the Management of Traumatic Hemothorax (HTX) and Pneumothorax (PTX) Management

Traumatic hemothorax and pneumothorax (HTX/PTX) are traditionally treated with large-bore chest tubes, which can lead to pain and complications. Recent studies suggest pigtail catheters can be utilized as a non-inferior alternative. The Departments of Surgery and Emergency Medicine at NewYork Presbyterian – Weill Cornell Medical Center developed an institutional guideline to standardize tube size for treating traumatic HTX/PTX, aiming to reduce the use of large-bore thoracotomy tubes without causing adverse patient outcomes. This project at NYP-WCM included patients over 18 years of age admitted with thoracic injuries resulting in HTX or PTX treated with a chest tube from January 2022 to November 2023. Patients were identified through ICD codes in the trauma registry and electronic medical record. The primary outcome was adherence to the newly developed guideline for placing thoracostomy tubes. Conversion from pigtail to larger-bore chest tube and other adverse events were secondary outcomes. We identified 18 pre-guideline and 27 post-guideline HTX/PTX patients meeting the criteria. Before the guideline implementation, 15 out of 18 patients (83%) received care consistent with the guideline (no large-bore chest). After implementation, 25 out of 27 patients (93%) received care consistent with the guideline. Based on chart review, none of the patients in the pigtail cohort experienced complications or required conversion to a larger chest tube. Although the impact was modest, implementation of the institutional guideline correlates with a reduction in “unnecessary” large-bore chest tubes for treating traumatic HTX/PTX and showed a trend toward pigtail adoption. Placement of pigtails was not linked to negative complications or treatment failure, indicating a non-inferior safety and effectiveness profile for addressing traumatic HTX/PTX.

Is there a change in the view of treatment for primary spontaneous pneumothorax?: The effect of thoracic CT and autologous blood pleurodesis: a retrospective cohort study.

This study investigated recurrence rates and treatment efficacy based on tomographic findings during a long-term follow-up after primary spontaneous pneumothorax (PSP) treatment. We retrospectively analyzed patients with PSP treated at our hospital between 2003 and 2020. Patients were categorized into 2 groups based on computed tomography (CT) findings: group 1 (no bulla/bleb) and group 2 (bullae-bleb <3 cm). Data on demographics, recurrence, treatment methods, and outcomes were also collected and compared. A total of 251 PSP cases were evaluated, predominantly male (93.6%) with a mean age of 29.23 ± 1.14 years. Most cases (57%) occurred on the right side. Recurrence rates were highest within the first year (77.8%), with the first and second recurrences occurring at rates of 26% and 27.3%, respectively. In group 1 (n = 117), conservative treatment was applied in 15 cases, tube thoracostomy in 81, autologous blood pleurodesis (ABP) in 19, and surgery in 12. Recurrence rates were 46.6%, 21%, 5.3%, and 8.3%, respectively. In group 2 (n = 134), the recurrence rates were 50%, 32.7%, 20%, and 3.1%, respectively (P < .001). No mortality was observed for any patient. The treatment groups included conservative (n = 19), thoracostomy (n = 179), ABP (n = 34), and surgical (n = 44) groups. Recurrence rates were 47.3%, 27.4%, 11.8% (group 1: 5.3%, group 2: 20%, P = .035), and 4.5% (0% vs 6.3%), respectively. ABP effectively reduced recurrence in group 1 PSP patients without bullae or blebs on CT, potentially avoiding surgery. Video-assisted thoracoscopic surgery should be preferred in group 2 cases with bullae or blebs to minimize recurrence. These results underscore the importance of tailoring treatment strategies based on CT findings to optimize PSP management outcomes.

Diaphragmatic Herniation with Pneumothorax Due to Barotrauma – Lessons to Learn: A Case Report

Diaphragmatic hernia is usually congenital or follows thoracoabdominal injury. Diaphragmatic hernia combined with pneumothorax is a rare combination in the clinical setting, where pneumothorax is usually secondary to hollow viscera perforation in the long-term complications of diaphragmatic herniation or rupture of ectopic endometrium over the diaphragm during menstruation. Unlike the aforementioned conditions, we describe a 67-year-old man with chronic diaphragmatic hernia who suffered from pneumothorax and pneumoperitoneum secondary to pulmonary bulla by barotrauma during mechanical ventilation. Computed tomography showed scattered free gas in the thoracic and abdominal cavities, while there was no tenderness and rebound tenderness. The patient was managed conservatively with low PEEP and a lung-protective mechanical ventilation strategy. Finally, the oxygenation index gradually rose from 58 to 107. Unfortunately, in light of the patient’s poor clinical status and significant comorbidities, the patient passed away peacefully 3 weeks after hospital admission. Diaphragmatic hernia combined with pneumothorax should be differentiated from tension pneumothorax. Whether to intubate chest drainage depends on the cause of pneumothorax and pneumoperitoneum, as well as the risks and benefits of chest drainage. Additionally, mechanical ventilation should be applied cautiously, and respiratory parameters should be adjusted reasonably in patients at high risk of pneumothorax.

Usefulness of Preoperative Prognostic Nutritional Index in Secondary Spontaneous Pneumothorax

BackgroundThe prognostic nutritional index has been identified as a predictor of postoperative outcomes in various fields. We investigated the usefulness of the prognostic nutritional index as a risk factor for postoperative complications in secondary spontaneous pneumothorax. MethodsIn this retrospective study, patients who underwent surgery for secondary spontaneous pneumothorax were reviewed. The associations among the prognostic nutritional index, body mass index, and performance status were examined, and risk factors for postoperative complications were investigated in a multivariate analysis. In the subgroup analysis, on the basis of the receiver operating characteristics, we divided patients into high– and low–prognostic nutritional index groups and investigated the utility of the prognostic nutritional index for postoperative complications. ResultsOf 91 patients who underwent surgery for secondary spontaneous pneumothorax, 34 patients with postoperative complications were included. The prognostic nutritional index was significantly positively and negatively correlated with body mass index (P < .001) and performance status (P < .001), respectively. Multivariate analysis revealed that a decreased prognostic nutritional index was an independent risk factor for postoperative complications (P = .0048). In the subgroup analysis, the postoperative outcomes, including the duration of chest tube placement (P = .042), hospital stay (P = .0014), complications (P = .0089), and mortality (P = .044), were significantly worse in the low– than in the high–prognostic nutritional index group. ConclusionsThe prognostic nutritional index may be useful for evaluating the severity of secondary spontaneous pneumothorax in preoperative patients and may be a risk for postoperative complications.

Effect of preoperative natural killer cell on postoperative pulmonary complications in patients of lung cancer − A single-center retrospective cohort study

BackgroundThe effect of preoperative natural killer (NK) cell abnormalities on postoperative pulmonary complications (PPCs) after thoracoscopic radical resection of lung cancer is still unclear. The main purpose of this study was to investigate the relationship between the preoperative NK cell ratio and PPCs. MethodsThe patients who underwent thoracoscopic radical resection for lung cancer were divided into a normal group and an abnormal group according to whether the proportion of preoperative NK cells was within the reference range. The main outcome was the incidence of PPCs during postoperative hospitalization. The demographic and perioperative data were collected. Propensity score matching was used to exclude systematic bias. Univariate logistic regression was used to test the relationship between the preoperative NK cell ratio and the incidence of PPCs. The restrictive cubic spline curve was used to analyze the dose–effect relationship between the preoperative NK cell ratio and the incidence of PPCs. ResultsA total of 4161 patients were included. After establishing a matching cohort, 910 patients were included in the statistical analysis. The incidence of PPCs in the abnormal group was greater than that in the normal group (55.2% vs. 31.6%). The incidence of PPCs first decreased and then increased with increasing NK cell ratio. The proportion of patients with Grade 3 or higher PPCs in the normal group was lower than that in the abnormal group [108 (23.7%) vs. 223 (49%)]. The indwelling time of the thoracic drainage tube in the abnormal group was longer than that in the normal group [3 (3, 4) vs. 3 (3, 5)]. A preoperative abnormal NK cell ratio constituted a risk factor for PPCs in each subgroup. ConclusionLung cancer patients with an abnormal proportion of peripheral blood NK cells before surgery were more likely to develop PPCs, their disease degree was more severe, and they had a prolonged duration of chest tube indwelling. Compared with those with abnormally high NK cell ratios, those with abnormally low NK cell ratios had more pronounced PPCs.

Shortness of breath on the day of discharge: an early alert for post-discharge complications in patients undergoing lung cancer surgery

PurposeSymptom assessment based on patient-reported outcome (PRO) can correlate with disease severity, making it a potential tool for threshold alerts of postoperative complications. This study aimed to determine whether shortness of breath (SOB) scores on the day of discharge could predict the development of post-discharge complications in patients who underwent lung cancer surgery.MethodsPatients were from a study of a dynamic perioperative rehabilitation cohort of lung cancer patients focusing on patient-reported outcomes. Patients were assessed using the Perioperative Symptom Assessment Scale for Lung surgery (PSA-Lung). Logistic regression model was used to examine the potential association between SOB on the day of discharge and complications within 3 months after discharge. The post-discharge complications were taken as the anchor variable to determine the optimal cutpoint for SOB on the day of discharge.ResultsComplications within 3 months post-discharge occurred in 71 (10.84%) of 655 patients. Logistic regression analysis revealed that being female (OR 1.764, 95% CI 1.006–3.092, P < 0.05) and having two chest tubes (OR 2.026, 95% CI 1.107–3.710, P < 0.05) were significantly associated with post-discharge complications. Additionally, the SOB score on the day of discharge (OR 1.125, 95% CI 1.012–1.250, P < 0.05) was a significant predictor. The optimal SOB cutpoint was 5 (on a scale of 0–10). Patients with an SOB score ≥ 5 at discharge experienced a lower quality of life 1 month later compared to those with SOB score<5 at discharge (73 [50–86] vs. 81 [65–91], P < 0.05).ConclusionSOB on the day of discharge may serve as an early warning sign for the timely detection of 3 month post-discharge complications.

Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set.

Small chest drains are used in many centers as the default drainage strategy for various pleural effusions. This can lead to drain overuse, which may be harmful. This study aimed to reduce chest drain overuse. We studied consecutive pleural procedures performed in the radiology department before (August 1, 2015, to July 31, 2016) and after intervention (September 1, 2019, to January 31, 2020). Chest drains were deemed indicated or not based on criteria established by a local interdisciplinary work group. The intervention consisted of a pleural drainage order set embedded in electronic medical records. It included indications for chest drain insertion, prespecified drain sizes for each indication, fluid analyses, and postprocedure radiography orders. Overall chest drain use and proportion of nonindicated drains were the outcomes of interest. We reviewed a total of 288 procedures (pre-intervention) and 155 procedures (post-intervention) (thoracentesis and drains). Order-set implementation led to a reduction in drain use (86.5% vs 54.8% of all procedures, P < .001) and reduction in drain insertions in the absence of an indication (from 45.4% to 29.4% of drains, P = .01). The need for repeat procedures did not increase after order-set implementation (22.0% pre vs 17.7% post, P = .40). Complication rates and length of hospital stay did not differ significantly after the intervention. More pleural infections were treated with drain sizes of 12Fr and greater (31 vs 70%, P < .001) after order-set deployment, and direct procedural costs were reduced by 27 CAN$ per procedure. Implementation of a pleural drainage order-set reduced chest drain use, improved procedure selection according to clinical needs, and reduced direct procedural costs. In institutions where small chest drains are used as the default drainage strategy for pleural effusions, this order set can reduce chest drain overuse.

A comparison of three-port and four-port Da Vinci robot-assisted thoracoscopic surgery for lung cancer: a retrospective study

BackgroundAt present, research comparing the short-term postoperative outcomes of anatomical resection in lung cancer under different ports of da Vinci robot-assisted surgery is insufficient. This report aimed to compare the outcomes of three-port and four-port da Vinci robot-assisted thoracoscopic surgery for radical dissection of lung cancer.Methods171 consecutive patients who presented to our hospital from January 2020 to October 2021 with non-small cell lung cancer and treated with da Vinci robot-assisted thoracoscopic surgery for radical resection of lung cancer were retrospectively collected and divided into the three-port group (n = 97) and the four-port group (n = 74). The general clinical data, perioperative data and life quality were individually compared between the two groups.ResultsAll the 171 patients successfully underwent surgeries. Compared to the four-port group, the three-port group had comparable baseline characteristics in terms of age, sex, tumor location, tumor size, history of chronic disease, pathological type, and pathological staging. The three-port group also had shorter operation time, less intraoperative blood loss, lower chest tube drainage volume, shorter postoperative hospitalization stay durations, but showed no statistically significant difference (P > 0.05). Postoperative 24, 48 and 72 h visual analogue scale pain scores were lower in the three-port group (p < 0.001). No significant difference was observed between the two groups in the hospitalization costs (P = 0.664), number or stations of total lymph node dissected (p > 0.05) and postoperative respiratory complications (P > 0.05).ConclusionsThe three-port robot-assisted thoracoscopic surgery is safe and effective and took better outcomes than the four-port robot-assisted thoracoscopic surgery in non-small cell lung cancer.

Uniportal versus multiportal video-assisted thoracoscopic surgery for spontaneous pneumothorax

BackgroundMultiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has emerged as an alternative aiming to minimize surgical morbidity. This study aims to strengthen the evidence on the safety and efficiency of uVATS compared to mVATS.MethodsFrom January 2004 to December 2020, records of patients who had undergone surgical treatment for primary or secondary spontaneous pneumothorax were evaluated for eligibility. Patients who had undergone pleurectomy combined with bullectomy or apical wedge resection via uVATS or mVATS were included. Surgical characteristics and postoperative data were compared between patients who had undergone surgery via uVATS or mVATS. Univariable and multivariable analyses were performed to determine whether the surgical approach was associated with any complication (primary outcome), major complications (i.e., Clavien-Dindo ≥ 3), recurrence, prolonged hospitalization or prolonged chest drainage duration (secondary outcomes).ResultsA total of 212 patients were enrolled. Patients treated via uVATS (n = 71) and mVATS (n = 141) were significantly different in pneumothorax type (secondary spontaneous; uVATS: 54 [76%], mVATS: 79 [56%]; p = 0.004). No significant differences were observed in (major) complications and recurrence rates between both groups. Multivariable analyses revealed that the surgical approach was no significant predictor for the primary or secondary outcomes.ConclusionsThis study indicates that uVATS is non-inferior to mVATS in the surgical treatment of spontaneous pneumothorax regarding safety and efficiency, and thus the uVATS approach has the potential for further improvements in the perioperative surgical care for spontaneous pneumothorax.

Complete transection of the bilateral main bronchus in a 5-year-old patient: a case report

BackgroundTracheobronchial injuries caused by blunt chest trauma are rare in children, and such injuries usually involve multiple organs. Most cases involve respiratory failure on the way to the hospital, and the mortality rate is high. Herein, we describe the case of a 5-year-old patient who fell from an electric vehicle, causing complete rupture of the bilateral main bronchus.Case presentationWe treated a 5-year-old patient with complete bilateral main bronchus rupture. Chest computed tomography (CT) failed to detect bronchial rupture. Continuous closed thoracic drainage resulted in a large amount of bubble overflow. Tracheal rupture was suspected. Fibreoptic bronchoscopy revealed complete rupture of the right main bronchus and rupture of the left main bronchus. Emergency tracheoplasty was performed under cardiopulmonary bypass (CPB). During the operation, we found that the bilateral main bronchi were completely ruptured. Postoperative recovery was smooth. The traditional surgical method for treating these injuries is lateral thoracotomy. However, a median sternotomy provides a better opportunity for selective repair. Extracorporeal circulation-assisted surgery is required for patients with unstable breathing.ConclusionComplete fractures of the bilateral main bronchi are rare. Bronchial rupture should be suspected in the presence of expansion defect-dropped lungs and massive air leakage despite tube thoracostomy in haemopneumothorax developing after thoracic trauma. Extracorporeal circulation-assisted tracheoplasty is a relatively safe option for children whose respiratory system is difficult to maintain, thus ensuring oxygenation ventilation and a clear surgical field.

Computed Tomography (CT)-Guided Needle Biopsy of Lung Lesions: A Single Center Experience.

(1) Objective: Lung cancer is one of the leading causes of cancer death among men and women across the globe. The accurate and timely diagnosis of lung lesions is of paramount importance for prognosis. This single-center study is the first to assess the diagnostic yield and complication rate of a computed tomography (CT)-guided needle biopsy of pulmonary parenchymal and pleural nodules in an academic training center in the United States. (2) Methods: This is a retrospective study approved by IRB. Patients who underwent CT-guided needle biopsy between 2016 and 2020 were reviewed. A CT-guided needle biopsy involving mediastinal lesions was excluded, focusing only on lung parenchymal and pleural lesions. A CT-guided needle biopsy aborted at any point during the procedure was also excluded from this study. (3) Results: 1063 patients were included in this study; 532 were males, and 531 were females. Lesion size ranged from 0.26 cm to 9.2 cm. 1040 patients received diagnoses, among which 772 had a specific diagnosis, and 268 had nonspecific inflammatory or non-malignant diagnoses. Twenty-three cases were non-diagnostic. Among the patients with specific diagnoses, 691 were malignant, 5 were hamartomas, 30 were fungal infections, 6 were acid-fast-positive organisms, and 40 were unspecified atypical cells. Of the patients that had a malignant diagnosis, 317 were adenocarcinoma, 197 were squamous cell carcinoma, 26 were a neuroendocrine tumor, 45 were non-small cell carcinoma (undifferentiated), 17 were small cell carcinoma, and 89 were other metastatic malignancies to the lung. Various common complications, including pneumothorax (337), hemorrhage (128), and hemoptysis (17), were observed, and 42 of the cases required chest tube intervention; others were treated with observation. Other rare complications observed included hemothorax (4) and oxygen desaturation (2), and there was no death in this series. (4) Conclusions: CT-guided needle biopsy is a reliable diagnostic modality for patients with lung parenchymal and pleural nodules, and it can effectively distinguish between benign and cancerous lesions before invasive procedures such as video-assisted thoracoscopy (VATs) or thoracotomy are planned. Our study showed a higher rate of pneumothorax and pulmonary hemorrhage compared to the rates established in guidelines, attributable to the varying experience level in a busy training academic center.

First-in-human use of a new robotic electromagnetic navigation bronchoscopic platform with integrated Tool-in-Lesion Tomosynthesis (TiLT) technology for peripheral pulmonary lesions: The FRONTIER study.

As the presentation of pulmonary nodules increases, the importance of a safe and accurate method of sampling peripheral pulmonary nodules is highlighted. First-generation robotic bronchoscopy has successfully assisted navigation and improved peripheral reach during bronchoscopy. Integrating tool-in-lesion tomosynthesis (TiLT) may further improve yield. We performed a first-in-human clinical trial of a new robotic electromagnetic navigation bronchoscopy system with integrated digital tomosynthesis technology (Galaxy System, Noah Medical). Patients with moderate-risk peripheral pulmonary nodules were enrolled in the study. Robotic bronchoscopy was performed using electromagnetic navigation with TiLT-assisted lesion guidance. Non-specific results were followed up until either a clear diagnosis was achieved or repeat radiology at 6 months demonstrated stability. Eighteen patients (19 nodules) were enrolled. The average lesion size was 20 mm, and the average distance from the pleura was 11.6 mm. The target was successfully reached in 100% of nodules, and the biopsy tool was visualized inside the target lesion in all cases. A confirmed specific diagnosis was achieved in 17 nodules, 13 of which were malignant. In one patient, radiological monitoring confirmed a true non-malignant result. This translates to a yield of 89.5% (strict) to 94.7% (intermediate). Complications included one pneumothorax requiring observation only and another requiring an overnight chest drain. There was one case of severe pneumonia following the procedure. In this first-in-human study, second-generation robotic bronchoscopy using electromagnetic navigation combined with integrated digital tomosynthesis was feasible with an acceptable safety profile and demonstrated a high diagnostic yield for small peripheral lung nodules.