BEST EVIDENCE TOPIC – THORACIC
Interactive CardioVascular and Thoracic Surgery 18 (2014) 671–675 doi:10.1093/icvts/ivt563 Advance Access publication 30 January 2014
Is it safe not to drain the pneumonectomy space? Karim Morcos*, Kasra Shaikhrezai and Alan J.B. Kirk Department of Thoracic Surgery, Golden Jubilee National Hospital, Clydebank, UK * Corresponding author. Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St., Clydebank G81 4DY, UK. Tel: +44-141-9515000; fax: +44-141-9515603; e-mail: [email protected] (K. Morcos). Received 16 November 2013; received in revised form 23 December 2013; accepted 30 December 2013
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether it is safe not to position any chest drain into the pneumonectomy space at the conclusion of the procedure. Altogether 381 relevant studies were identified of which 11 represented the best evidence to answer the question. The author, journal, date, country of publication, alternative methods of postpneumonectomy space (PPS) management, complications and relevant outcomes are tabulated. The majority of studies are on the basis of expert opinion or small cohorts. Major cohorts, by which the pneumonectomy outcomes have been examined, demonstrated that the rates of complications related to pneumonectomy space management such as empyema, bronchopleural fistula, mediastinal shift and major bleeding requiring reopening are very low. In a large cohort where 408 patients underwent pneumonectomy the rate of relevant complications was low and also it was concluded that the PPS drainage is not necessary. Two separate expert opinions were in agreement that needle aspiration in the absence of a drainage system is adequate for the management of PPS and avoiding a mediastinal shift. One small cohort and one institutional audit directly examined the impact of a drainage versus no drainage approach in the management of PPS. Although neither study could show a significant superiority of one method over another, they recommended adopting a unified institutional protocol for current departmental practice. They also emphasized that larger cohorts are required to examine the superiority of different strategies for PPS management. In a cohort of 291 patients, it was demonstrated that patients with drainage with underwater seal are more at risk of postpneumonectomy oedema. A recent review published as a book chapter appraised the relevant literature in both humans and animals. The authors concluded that the simplicity of a no-drainage system is notable; however, a balanced drainage might be recommended for local protocols. We conclude that although the current evidence is not adequate to examine the different aforementioned approaches, not draining the pneumonectomy space can be performed safely. Keywords: Pneumonectomy • Pneumonectomy space • Drain
INTRODUCTION
SEARCH STRATEGY
A best evidence topic was constructed according to a structured protocol, which is comprehensively described in the ICVTS [1].
Medline from 1948 to October Week 4 2013 using the OVID SP interface was searched utilizing the following strategy: ( pneumonectomy.mp OR pneumonectomy space.mp) and (drain$.mp) and (exp complications/). The search was limited to humans and English language.
CLINICAL SCENARIO Your new consultant assists you to perform a pneumonectomy procedure. At the conclusion of the operation, he instructs you to close the thoracotomy wound without insertion of any chest drain into the pneumonectomy space. This is the first time you experience a different practice as previously you have been always asked to leave a single intercostal chest drain into the pleural cavity following pneumonectomy. You resolve to check for the safety of this approach.
SEARCH OUTCOME Three hundred and eighty-one papers were identified utilizing the reported search strategy. Eleven of these were selected as representing the best evidence on this topic and summarized in Table 1.
THREE-PART QUESTION
COMMENTS
In patients [undergoing a pneumonectomy] is a [drain] or [no drainage] the best treatment in terms of [safety, pain and risk of empyema]?
Postpneumonectomy space (PPS) management has remained controversial with two different approaches: drainage versus no drainage. Main postpneumonectomy complications that are
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
Abstract
K. Morcos et al. / Interactive CardioVascular and Thoracic Surgery
672
Table 1: Summary of best evidence papers in chronological order Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Rammohan et al. (2011), Chapter: Management of the pleural space early after pneumonectomy, Book: Difficult Decisions in Thoracic Surgery, UK [2]
Critical appraisal of current literature (5 papers) and expert opinion on various methods of PPS management in both humans and animals
Surgical emphysema, postpneumonectomy pulmonary oedema, length of hospital stay
The clinical outcome was satisfactory in all methods (drainage vs no drainage)
Authors’ personal view is that the no-tube system has the advantage of simplicity and theoretically reduces the risk of infection They recommend that if there is a need to review an institutional protocol, adopting the balanced drainage system should be considered
Expert opinion (level 3 evidence)
Gudbjartsson et al. (2008), Ann Thorac Surg, Sweden [3]
130 patients underwent pneumonectomy (with or without preoperative adjuvant therapy)
Operative mortality and postoperative complications
BPF (n = 8, 6.1%) Empyema (n = 3, 2.3%) Reopening for bleeding (n = 4, 3.0%)
Retrospective cohort (level 3 evidence)
In-hospital mortality (n = 1, 0.7%) All patients received one chest tube positioned in the pneumonectomy space and was removed in 12 h if no major bleeding occurred Pai et al. (2007), Heart Lung Circ, UK [4] Audit/expert opinion (level 3 evidence)
Thomson and Ferreira Filho (2006), J Bras Pneumol, Brazil [5] Retrospective cohort (level 3 evidence)
Audit of current institutional practice in the management of PPS in 20 patients (all drained): Group A with 15 patients (a clamped drain with intermittent release) vs Group B with 5 patients (an unclamped drain)
Mediastinal shift, empyema
46 patients who underwent pneumonectomy were divided into two groups: drainage group (n = 21, 45.7%) and no-drainage group (n = 25, 54.3%)
Postoperative mortality, complications and length of in-hospital stay
Mediastinal shift = 9.7% (Group A) (range 5.0–12.9%) and 9.2% (Group B) (range 5.3–12.2%)
The rate of complications related to PPS management is low More BPF occurred on the right side as the bronchial stump tends to remain in the pleural cavity while the left bronchial stump retracts into the mediastinum Pneumonectomy is a safe operation with low rates of mortality and complications
No evidence in the literature on which to base a policy for management of PPS and there is no consensus in the text books
Surgical emphysema was worse in Group A (not statistically significant) Subcutaneous emphysema (drainage group = 4, non-drainage group = 8)
Authors avoid advising on a particular method of PPS management
Mediastinal shift in 2 (4.3%) patients from the non-drainage group in whom needle aspiration was performed for mediastinal stabilization
Authors concluded that, in the absence of any consensus on PPS management, their study can be used as a starting point for more powered studies
In-hospital stay was longer in the drainage group (10.2 vs 6.5 days) although not significant statistically (P = 0.172) No mortality was reported Ludwig et al. (2005), Ann Thorac Surg, Germany [6] Retrospective cohort (level 3 evidence)
310 patients underwent sleeve lobectomy or pneumonectomy (n = 194, 62.6%)
Postoperative complications, in-hospital mortality and 5-year survival
All patients with pneumonectomy had one chest drain positioned into the empty pleural cavity for 12–24 h
The rate of complications related to PPS management is low Authors believe that sleeve lobectomy is superior to
Continued
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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Empyema (n = 2, 1.0%)
pneumonectomy with no further comment on preferable PPS management
Reopening for bleeding (n = 3, 1.5%)
Wolfe and Lewis (2002), Chest Surg Clin N Am, USA [7]
Expert opinion on various methods of PPS management
Advantages and disadvantages of two major concepts in postpneumonectomy management of empty pleural cavity
Most patients who undergo pneumonectomy do not require PPS drainage
In order to maintain the intrapleural pressure or avoid mediastinal shift, needle aspiration is adequate in the absence of a drainage system
713 patients underwent pneumonectomy for primary malignancy, metastatic and benign disease
Empyema and BPF
Empyema (n = 53, 7.5%)
Authors demonstrate that the timing of chest tube removal influences the incidence of empyema as well as BPF
Expert opinion (level 3 evidence) Deschamps et al. (2001), Ann Thorac Surg, USA [8] Retrospective cohort (level 3 evidence)
BPF (n = 32, 4.5%) No PPS drainage performed in 59 (8.2%) patients
Completion of pneumonectomy performed in 115 (16.1%) of patients
Pezzella et al. (2000), Asian Cardiovasc Thorac Ann, USA [9]
Expert opinion on various methods of PPS management
In 517 (72.5%), the inserted chest drain was removed prior to patient transfer from the operation theatre. The rate of empyema was significantly lower (P = 0.011) in this group of patients Mediastinal shift
The immediate postoperative goal is to prevent acute mediastinal shifts that might cause cardiovascular collapse
Expert opinion (level 3 evidence)
No complications reported for patients with no drainage of PPS
Authors emphasize that there is no solid evidence on either approach although they believe that no drainage with needle aspiration where required can be the standard protocol in routine uncomplicated pneumonectomy Balanced drainage is recommended in complicated cases with increased bleeding or inflamed tissue
Deslauriers et al. (1999), Chest Surg Clin N Am, USA [10] Expert opinion (level 3 evidence)
Expert opinion on various methods of PPS management: advantages and disadvantages of PPS drainage
Mediastinal shift, bleeding, infection, postpneumonectomy oedema, mobility and coughing mechanism
Advantages of PPS drainage: monitoring of postoperative bleeding, preventing wound dehiscence in major pneumonectomies with chest wall resection, useful for intrapleural injection of chemotherapy agents, maintain the mediastinum in its ideal physiological position (balanced drainage)
PPS drainage needs to be considered as the last resort for complex pneumonectomies; otherwise drainage is generally not necessary
Disadvantages of PPS drainage: not required in majority of cases, additional burden on patients’ mobility, risk of detachment, impairing cough mechanism, subcutaneous
Continued
BEST EVIDENCE TOPIC
Mediastinal shift was not reported
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674
Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
emphysema (balanced drainage), risk of inadvertent connection of chest tube to suction Deslauriers et al. (1998), Chest Surg Clin N Am, USA [11]
291 patients underwent pneumonectomy
Mortality and morbidity specifically postpneumonectomy oedema in patients with pleural drainage vs no drainage
Postpneumonectomy oedema occurred in 13 patients: 2 with no drainage vs 11 with pleural drainage (P = 0.009)
Authors do not recommend drainage of the pneumonectomy space
408 patients underwent pneumonectomy for bronchogenic carcinoma or others (bronchiectasis, bullous emphysema, etc.) without any PPS drainage
Pneumonectomy space bleeding and infection
Satisfactory mediastinal stabilization in all patients
Authors conclude that tube drainage of PPS is not necessary
Retrospective cohort (level 3 evidence) Bhattacharya and Polk (1973), Chest, USA [12] Retrospective cohort (level 3 evidence)
Stabilizing the mediastinum by creating intrapleural negative pressure and strict antibiotic therapy (intravenous and intrapleural)
Death: 43 (10.5%) Empyema: 16 (3.9%) BPF: 6 (1.5%) Re-exploration for bleeding: 0
BPF: bronchopleural fistula; PPS: postpneumonectomy space.
deemed to be linked with PPS management are mediastinal shift, pulmonary oedema, major bleeding requiring reopening, surgical emphysema, empyema and bronchopleural fistula (BPF). According to a survey in the UK 20% of surgeons do not position any drain in the pneumonectomy space [13]. Four major cohorts demonstrated that the rates of empyema (1.0–7.5%), BPF (4.5– 6.1%) and reopening due to bleeding (1.5–3.0%) are low [3, 6, 8, 12]. In an institutional audit of 20 patients with pneumonectomy and PPS drainage different strategies to manage the tube thoracostomy were compared in two groups: clamp with intermittent release versus unclamped drainage [4]. Mediastinal shift occurred in both groups. Authors also reviewed the current evidence in the major thoracic surgery text books. They concluded that there is no consensus and current practice is not strong enough to influence the practice. Thomson and Ferreira Filho [5] in a largest available cohort of 46 pneumonectomy patients directly examined the impact of drainage (n = 21, 45.7%) versus no drainage (n = 25, 54.3%). The non-drainage group developed more surgical emphysema, which was not statistically significant. All mediastinal shifts (n = 2, 4.3%) occurred in the non-drainage group in whom needle aspiration stabilized the mediastinum. In-hospital stay was longer in the drainage group (10.2 vs 6.5), which was not statistically significant. The authors suggested having their study as a baseline for more powerful studies in future. Two expert reviews [7, 9] argued that although there is a paucity of PPS management in the literature, the favourable approach is a no-drainage policy, with needle aspiration for mediastinal stabilization when it is required. Bhattacharya et al. [12] in a cohort of 408 patients who underwent pneumonectomy without any drainage system demonstrated that mediastinal stabilization was achieved satisfactorily in all patients with no re-exploration for
bleeding. They also reported a low empyema (3.9%) as well as BPF (1.5%) rate. The authors concluded that PPS drainage is not necessary. Another cohort of 291 patients [11] demonstrated that patients with drainage after pneumonectomy develop more pulmonary oedema when compared with those with a no-drainage approach. A year later the study was appraised [10] and accompanied by an expert opinion regarding the advantages and disadvantages of PPS drainage versus no drainage. The authors concluded that PPS drainage in straightforward pneumonectomies might not be necessary. A recent review of the literature with an unlimited search strategy identified five papers evaluating the impact of PPS management in both humans and animals [2]. Surgical emphysema, postpneumonectomy pulmonary oedema and length of hospital stay were studied. The outcome was satisfactory in both groups: drainage versus no drainage. The authors emphasized that due to lack of enough evidence it is not possible to identify the superior approach; however, their personal view on institutional protocol was more in favour of a balanced drainage system.
CONCLUSION The rate of postpneumonectomy complications that might be prevented or monitored by pneumonectomy space drainage is very low [3, 6, 8, 12]. Surgeons who advocate pneumonectomy space management without a chest drain claim that this reduces the risk of infection as well as other chest drain-related complications. There is no consensus on the PPS drainage and the evidence is not strong enough to influence the practice. Although recommendations have remained at the level of expert opinion, no inferiority
was observed in either method: drainage versus no drainage. It is recommended that each thoracic surgery department implement a unified protocol for the management of the pneumonectomy space and it is of importance for all clinicians in the field to know the advantages and disadvantages of both techniques. The strategy of pneumonectomy space management is fundamentally driven by the pros and cons of drainage versus no drainage in individual patients. For instance, a patient on antiplatelet therapy with a high risk of postoperative bleeding is a favourable candidate for drain insertion at the conclusion of pneumonectomy.
[3]
[4]
[5]
[6]
CLINICAL BOTTOM LINE [7]
Not draining the pneumonectomy space can be an option in patients who undergo uncomplicated pneumonectomy.
[8]
Conflict of interest: none declared.
[9] [10]
REFERENCES [1] Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405–9. [2] Rammohan KS, Pai VB, Treasure T. Management of the pleural space early after pneumonectomy. In: Ferguson MK (ed). Difficult Decisions in
[11] [12]
[13]
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Thoracic Surgery: An Evidence-Based Approach. London: Springer, 2011, 161–4. Gudbjartsson T, Gyllstedt E, Pikwer A, Jönsson P. Early surgical results after pneumonectomy for non-small cell lung cancer are not affected by preoperative radiotherapy and chemotherapy. Ann Thorac Surg 2008;86: 376–82. Pai V, Gangoli S, Tan C, Rankin S, Utley M, Cameron R et al. How best to manage the space after pneumonectomy? Theory and experience but no evidence. Heart Lung Circ 2007;16:103–6. Thomson JC, Ferreira Filho OF. Post-pneumonectomy thoracic drainage: to drain or not to drain? A retrospective study. J Bras Pneumol 2006;32: 290–3. Ludwig C, Stoelben E, Olschewski M, Hasse J. Comparison of morbidity, 30-day mortality, and long-term survival after pneumonectomy and sleeve lobectomy for non-small cell lung carcinoma. Ann Thorac Surg 2005;79:968–73. Wolfe WG, Lewis CW Jr. Control of the pleural space after pneumonectomy. Chest Surg Clin N Am 2002;12:565–70. Deschamps C, Bernard A, Nichols FC 3rd, Allen MS, Miller DL, Trastek VF et al. Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence. Ann Thorac Surg 2001;72:243–7; discussion 248. Pezzella AT, Conlan A, Carroll GJ. Early management of the postpneumonectomy space. Asian Cardiovasc Thorac Ann 2000;8:398–402. Deslauriers J, Grégoire J. Techniques of pneumonectomy. Drainage after pneumonectomy. Chest Surg Clin N Am 1999;9:437–48; xii. Deslauriers J, Aucoin A, Gregoire J. Postpneumonectomy pulmonary edema. Chest Surg Clin North Am 1998;8:611–31. Bhattacharya SK, Polk JW. Management of postpneumonectomy space. Appraisal of a technique used in 408 consecutive cases. Chest 1973;63: 233. Khan IH, Vaughan R. A national survey of thoracic surgical practice in the UK. Int J Clin Pract 1999;53:252–6.
BEST EVIDENCE TOPIC
K. Morcos et al. / Interactive CardioVascular and Thoracic Surgery
Interactive CardioVascular and Thoracic Surgery 18 (2014) 671–675 doi:10.1093/icvts/ivt563 Advance Access publication 30 January 2014
Is it safe not to drain the pneumonectomy space? Karim Morcos*, Kasra Shaikhrezai and Alan J.B. Kirk Department of Thoracic Surgery, Golden Jubilee National Hospital, Clydebank, UK * Corresponding author. Department of Thoracic Surgery, Golden Jubilee National Hospital, Agamemnon St., Clydebank G81 4DY, UK. Tel: +44-141-9515000; fax: +44-141-9515603; e-mail: [email protected] (K. Morcos). Received 16 November 2013; received in revised form 23 December 2013; accepted 30 December 2013
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether it is safe not to position any chest drain into the pneumonectomy space at the conclusion of the procedure. Altogether 381 relevant studies were identified of which 11 represented the best evidence to answer the question. The author, journal, date, country of publication, alternative methods of postpneumonectomy space (PPS) management, complications and relevant outcomes are tabulated. The majority of studies are on the basis of expert opinion or small cohorts. Major cohorts, by which the pneumonectomy outcomes have been examined, demonstrated that the rates of complications related to pneumonectomy space management such as empyema, bronchopleural fistula, mediastinal shift and major bleeding requiring reopening are very low. In a large cohort where 408 patients underwent pneumonectomy the rate of relevant complications was low and also it was concluded that the PPS drainage is not necessary. Two separate expert opinions were in agreement that needle aspiration in the absence of a drainage system is adequate for the management of PPS and avoiding a mediastinal shift. One small cohort and one institutional audit directly examined the impact of a drainage versus no drainage approach in the management of PPS. Although neither study could show a significant superiority of one method over another, they recommended adopting a unified institutional protocol for current departmental practice. They also emphasized that larger cohorts are required to examine the superiority of different strategies for PPS management. In a cohort of 291 patients, it was demonstrated that patients with drainage with underwater seal are more at risk of postpneumonectomy oedema. A recent review published as a book chapter appraised the relevant literature in both humans and animals. The authors concluded that the simplicity of a no-drainage system is notable; however, a balanced drainage might be recommended for local protocols. We conclude that although the current evidence is not adequate to examine the different aforementioned approaches, not draining the pneumonectomy space can be performed safely. Keywords: Pneumonectomy • Pneumonectomy space • Drain
INTRODUCTION
SEARCH STRATEGY
A best evidence topic was constructed according to a structured protocol, which is comprehensively described in the ICVTS [1].
Medline from 1948 to October Week 4 2013 using the OVID SP interface was searched utilizing the following strategy: ( pneumonectomy.mp OR pneumonectomy space.mp) and (drain$.mp) and (exp complications/). The search was limited to humans and English language.
CLINICAL SCENARIO Your new consultant assists you to perform a pneumonectomy procedure. At the conclusion of the operation, he instructs you to close the thoracotomy wound without insertion of any chest drain into the pneumonectomy space. This is the first time you experience a different practice as previously you have been always asked to leave a single intercostal chest drain into the pleural cavity following pneumonectomy. You resolve to check for the safety of this approach.
SEARCH OUTCOME Three hundred and eighty-one papers were identified utilizing the reported search strategy. Eleven of these were selected as representing the best evidence on this topic and summarized in Table 1.
THREE-PART QUESTION
COMMENTS
In patients [undergoing a pneumonectomy] is a [drain] or [no drainage] the best treatment in terms of [safety, pain and risk of empyema]?
Postpneumonectomy space (PPS) management has remained controversial with two different approaches: drainage versus no drainage. Main postpneumonectomy complications that are
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
Abstract
K. Morcos et al. / Interactive CardioVascular and Thoracic Surgery
672
Table 1: Summary of best evidence papers in chronological order Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Rammohan et al. (2011), Chapter: Management of the pleural space early after pneumonectomy, Book: Difficult Decisions in Thoracic Surgery, UK [2]
Critical appraisal of current literature (5 papers) and expert opinion on various methods of PPS management in both humans and animals
Surgical emphysema, postpneumonectomy pulmonary oedema, length of hospital stay
The clinical outcome was satisfactory in all methods (drainage vs no drainage)
Authors’ personal view is that the no-tube system has the advantage of simplicity and theoretically reduces the risk of infection They recommend that if there is a need to review an institutional protocol, adopting the balanced drainage system should be considered
Expert opinion (level 3 evidence)
Gudbjartsson et al. (2008), Ann Thorac Surg, Sweden [3]
130 patients underwent pneumonectomy (with or without preoperative adjuvant therapy)
Operative mortality and postoperative complications
BPF (n = 8, 6.1%) Empyema (n = 3, 2.3%) Reopening for bleeding (n = 4, 3.0%)
Retrospective cohort (level 3 evidence)
In-hospital mortality (n = 1, 0.7%) All patients received one chest tube positioned in the pneumonectomy space and was removed in 12 h if no major bleeding occurred Pai et al. (2007), Heart Lung Circ, UK [4] Audit/expert opinion (level 3 evidence)
Thomson and Ferreira Filho (2006), J Bras Pneumol, Brazil [5] Retrospective cohort (level 3 evidence)
Audit of current institutional practice in the management of PPS in 20 patients (all drained): Group A with 15 patients (a clamped drain with intermittent release) vs Group B with 5 patients (an unclamped drain)
Mediastinal shift, empyema
46 patients who underwent pneumonectomy were divided into two groups: drainage group (n = 21, 45.7%) and no-drainage group (n = 25, 54.3%)
Postoperative mortality, complications and length of in-hospital stay
Mediastinal shift = 9.7% (Group A) (range 5.0–12.9%) and 9.2% (Group B) (range 5.3–12.2%)
The rate of complications related to PPS management is low More BPF occurred on the right side as the bronchial stump tends to remain in the pleural cavity while the left bronchial stump retracts into the mediastinum Pneumonectomy is a safe operation with low rates of mortality and complications
No evidence in the literature on which to base a policy for management of PPS and there is no consensus in the text books
Surgical emphysema was worse in Group A (not statistically significant) Subcutaneous emphysema (drainage group = 4, non-drainage group = 8)
Authors avoid advising on a particular method of PPS management
Mediastinal shift in 2 (4.3%) patients from the non-drainage group in whom needle aspiration was performed for mediastinal stabilization
Authors concluded that, in the absence of any consensus on PPS management, their study can be used as a starting point for more powered studies
In-hospital stay was longer in the drainage group (10.2 vs 6.5 days) although not significant statistically (P = 0.172) No mortality was reported Ludwig et al. (2005), Ann Thorac Surg, Germany [6] Retrospective cohort (level 3 evidence)
310 patients underwent sleeve lobectomy or pneumonectomy (n = 194, 62.6%)
Postoperative complications, in-hospital mortality and 5-year survival
All patients with pneumonectomy had one chest drain positioned into the empty pleural cavity for 12–24 h
The rate of complications related to PPS management is low Authors believe that sleeve lobectomy is superior to
Continued
K. Morcos et al. / Interactive CardioVascular and Thoracic Surgery
673
Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Empyema (n = 2, 1.0%)
pneumonectomy with no further comment on preferable PPS management
Reopening for bleeding (n = 3, 1.5%)
Wolfe and Lewis (2002), Chest Surg Clin N Am, USA [7]
Expert opinion on various methods of PPS management
Advantages and disadvantages of two major concepts in postpneumonectomy management of empty pleural cavity
Most patients who undergo pneumonectomy do not require PPS drainage
In order to maintain the intrapleural pressure or avoid mediastinal shift, needle aspiration is adequate in the absence of a drainage system
713 patients underwent pneumonectomy for primary malignancy, metastatic and benign disease
Empyema and BPF
Empyema (n = 53, 7.5%)
Authors demonstrate that the timing of chest tube removal influences the incidence of empyema as well as BPF
Expert opinion (level 3 evidence) Deschamps et al. (2001), Ann Thorac Surg, USA [8] Retrospective cohort (level 3 evidence)
BPF (n = 32, 4.5%) No PPS drainage performed in 59 (8.2%) patients
Completion of pneumonectomy performed in 115 (16.1%) of patients
Pezzella et al. (2000), Asian Cardiovasc Thorac Ann, USA [9]
Expert opinion on various methods of PPS management
In 517 (72.5%), the inserted chest drain was removed prior to patient transfer from the operation theatre. The rate of empyema was significantly lower (P = 0.011) in this group of patients Mediastinal shift
The immediate postoperative goal is to prevent acute mediastinal shifts that might cause cardiovascular collapse
Expert opinion (level 3 evidence)
No complications reported for patients with no drainage of PPS
Authors emphasize that there is no solid evidence on either approach although they believe that no drainage with needle aspiration where required can be the standard protocol in routine uncomplicated pneumonectomy Balanced drainage is recommended in complicated cases with increased bleeding or inflamed tissue
Deslauriers et al. (1999), Chest Surg Clin N Am, USA [10] Expert opinion (level 3 evidence)
Expert opinion on various methods of PPS management: advantages and disadvantages of PPS drainage
Mediastinal shift, bleeding, infection, postpneumonectomy oedema, mobility and coughing mechanism
Advantages of PPS drainage: monitoring of postoperative bleeding, preventing wound dehiscence in major pneumonectomies with chest wall resection, useful for intrapleural injection of chemotherapy agents, maintain the mediastinum in its ideal physiological position (balanced drainage)
PPS drainage needs to be considered as the last resort for complex pneumonectomies; otherwise drainage is generally not necessary
Disadvantages of PPS drainage: not required in majority of cases, additional burden on patients’ mobility, risk of detachment, impairing cough mechanism, subcutaneous
Continued
BEST EVIDENCE TOPIC
Mediastinal shift was not reported
K. Morcos et al. / Interactive CardioVascular and Thoracic Surgery
674
Table 1: (Continued) Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
emphysema (balanced drainage), risk of inadvertent connection of chest tube to suction Deslauriers et al. (1998), Chest Surg Clin N Am, USA [11]
291 patients underwent pneumonectomy
Mortality and morbidity specifically postpneumonectomy oedema in patients with pleural drainage vs no drainage
Postpneumonectomy oedema occurred in 13 patients: 2 with no drainage vs 11 with pleural drainage (P = 0.009)
Authors do not recommend drainage of the pneumonectomy space
408 patients underwent pneumonectomy for bronchogenic carcinoma or others (bronchiectasis, bullous emphysema, etc.) without any PPS drainage
Pneumonectomy space bleeding and infection
Satisfactory mediastinal stabilization in all patients
Authors conclude that tube drainage of PPS is not necessary
Retrospective cohort (level 3 evidence) Bhattacharya and Polk (1973), Chest, USA [12] Retrospective cohort (level 3 evidence)
Stabilizing the mediastinum by creating intrapleural negative pressure and strict antibiotic therapy (intravenous and intrapleural)
Death: 43 (10.5%) Empyema: 16 (3.9%) BPF: 6 (1.5%) Re-exploration for bleeding: 0
BPF: bronchopleural fistula; PPS: postpneumonectomy space.
deemed to be linked with PPS management are mediastinal shift, pulmonary oedema, major bleeding requiring reopening, surgical emphysema, empyema and bronchopleural fistula (BPF). According to a survey in the UK 20% of surgeons do not position any drain in the pneumonectomy space [13]. Four major cohorts demonstrated that the rates of empyema (1.0–7.5%), BPF (4.5– 6.1%) and reopening due to bleeding (1.5–3.0%) are low [3, 6, 8, 12]. In an institutional audit of 20 patients with pneumonectomy and PPS drainage different strategies to manage the tube thoracostomy were compared in two groups: clamp with intermittent release versus unclamped drainage [4]. Mediastinal shift occurred in both groups. Authors also reviewed the current evidence in the major thoracic surgery text books. They concluded that there is no consensus and current practice is not strong enough to influence the practice. Thomson and Ferreira Filho [5] in a largest available cohort of 46 pneumonectomy patients directly examined the impact of drainage (n = 21, 45.7%) versus no drainage (n = 25, 54.3%). The non-drainage group developed more surgical emphysema, which was not statistically significant. All mediastinal shifts (n = 2, 4.3%) occurred in the non-drainage group in whom needle aspiration stabilized the mediastinum. In-hospital stay was longer in the drainage group (10.2 vs 6.5), which was not statistically significant. The authors suggested having their study as a baseline for more powerful studies in future. Two expert reviews [7, 9] argued that although there is a paucity of PPS management in the literature, the favourable approach is a no-drainage policy, with needle aspiration for mediastinal stabilization when it is required. Bhattacharya et al. [12] in a cohort of 408 patients who underwent pneumonectomy without any drainage system demonstrated that mediastinal stabilization was achieved satisfactorily in all patients with no re-exploration for
bleeding. They also reported a low empyema (3.9%) as well as BPF (1.5%) rate. The authors concluded that PPS drainage is not necessary. Another cohort of 291 patients [11] demonstrated that patients with drainage after pneumonectomy develop more pulmonary oedema when compared with those with a no-drainage approach. A year later the study was appraised [10] and accompanied by an expert opinion regarding the advantages and disadvantages of PPS drainage versus no drainage. The authors concluded that PPS drainage in straightforward pneumonectomies might not be necessary. A recent review of the literature with an unlimited search strategy identified five papers evaluating the impact of PPS management in both humans and animals [2]. Surgical emphysema, postpneumonectomy pulmonary oedema and length of hospital stay were studied. The outcome was satisfactory in both groups: drainage versus no drainage. The authors emphasized that due to lack of enough evidence it is not possible to identify the superior approach; however, their personal view on institutional protocol was more in favour of a balanced drainage system.
CONCLUSION The rate of postpneumonectomy complications that might be prevented or monitored by pneumonectomy space drainage is very low [3, 6, 8, 12]. Surgeons who advocate pneumonectomy space management without a chest drain claim that this reduces the risk of infection as well as other chest drain-related complications. There is no consensus on the PPS drainage and the evidence is not strong enough to influence the practice. Although recommendations have remained at the level of expert opinion, no inferiority
was observed in either method: drainage versus no drainage. It is recommended that each thoracic surgery department implement a unified protocol for the management of the pneumonectomy space and it is of importance for all clinicians in the field to know the advantages and disadvantages of both techniques. The strategy of pneumonectomy space management is fundamentally driven by the pros and cons of drainage versus no drainage in individual patients. For instance, a patient on antiplatelet therapy with a high risk of postoperative bleeding is a favourable candidate for drain insertion at the conclusion of pneumonectomy.
[3]
[4]
[5]
[6]
CLINICAL BOTTOM LINE [7]
Not draining the pneumonectomy space can be an option in patients who undergo uncomplicated pneumonectomy.
[8]
Conflict of interest: none declared.
[9] [10]
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K. Morcos et al. / Interactive CardioVascular and Thoracic Surgery
