CORRESPONDENCE
Balanced Drainage
Spontaneous Pneumothorax
To the Editor:
To the Editor:
I wish to support the use of balanced drainage as outlined by Miller, Fleming, and Hatcher (Ann Thorac Surg 19:585, 1975). Since our original publication (Surgery 37:257,1955), we also have used this form of treatment for small postpneumonectomy bronchopleural fistulas with and without empyema. Often the fistulas heal. Therefore, we believe balanced drainage is useful not only in the management of a contaminated pleural space, but also in the treatment of frank empyema before mediastinal stabilization has occurred. Unlike many thoracic surgeons, we routinely drain the pleural cavity. We now use suction of a mean of -10 cm H,O, actually encouraging mediastinal shift to the side of operation to limit the size of the residual pleural space that could become infected. The physiological effects generally appear beneficial (Surg Clin North Am 53:623, 1973). Other advantages are ease of determining blood loss, prevention of compression of the remaining lung by fluid accumulation, and early detection of bronchial stump leaks. Drainage has not increased the incidence of postoperative empyema, as many who d o not drain have suspected. We have left catheters in an uninfected pleural space for as long as a week following pneumonectomy on many occasions. In spite of this, we have seen pleural infections only rarely. We leave the catheter in place for a much longer period in patients who have had less than a pneumonectomy, sometimes for several weeks until firm pleurodesis occurs. When there is merely a leakage of air from the lung and no air-containing pleural pocket, we have had no problem with infection. In patients who have large air-containing pleural pockets, we have encountered empyema with prolonged catheter drainage of several weeks. We usually remove the catheter from pneumonectomy spaces when the amount of fluid drainage is less than 200 ml in 24 hours. The great majority of our patients require drainage for no more than two or three days.
This concerns the paper ”Management of Spontaneous Pneumothorax” by Sibu P. Saha, M.D., and associates (Ann Thorac Surg 19:561, 1975). The authors are to be complimented for advocating an open thoracotomy more widely for the treatment of spontaneous pneuniothorax. However, we prefer a transaxillary thoracotomy with an incision in the second or third interspace since most of the disease is limited to the apex in the majority of these patients. This a p proach, combined with use of the autostapler device, simplifies the surgical procedure and minimizes postoperative discomfort to the patient compared with a standard thoracotomy.
Dnzlid V . Pecorn, M . D . Surgical Service Veternns Administrntion Center 1601 Kirkwood Hwy Wilmington, DE 19805
85
1. Reddy Penagnlirrir, M . D . 208 NW 2nd S t Mineral Wells, TX
76067
Balanced Drainage
Spontaneous Pneumothorax
To the Editor:
To the Editor:
I wish to support the use of balanced drainage as outlined by Miller, Fleming, and Hatcher (Ann Thorac Surg 19:585, 1975). Since our original publication (Surgery 37:257,1955), we also have used this form of treatment for small postpneumonectomy bronchopleural fistulas with and without empyema. Often the fistulas heal. Therefore, we believe balanced drainage is useful not only in the management of a contaminated pleural space, but also in the treatment of frank empyema before mediastinal stabilization has occurred. Unlike many thoracic surgeons, we routinely drain the pleural cavity. We now use suction of a mean of -10 cm H,O, actually encouraging mediastinal shift to the side of operation to limit the size of the residual pleural space that could become infected. The physiological effects generally appear beneficial (Surg Clin North Am 53:623, 1973). Other advantages are ease of determining blood loss, prevention of compression of the remaining lung by fluid accumulation, and early detection of bronchial stump leaks. Drainage has not increased the incidence of postoperative empyema, as many who d o not drain have suspected. We have left catheters in an uninfected pleural space for as long as a week following pneumonectomy on many occasions. In spite of this, we have seen pleural infections only rarely. We leave the catheter in place for a much longer period in patients who have had less than a pneumonectomy, sometimes for several weeks until firm pleurodesis occurs. When there is merely a leakage of air from the lung and no air-containing pleural pocket, we have had no problem with infection. In patients who have large air-containing pleural pockets, we have encountered empyema with prolonged catheter drainage of several weeks. We usually remove the catheter from pneumonectomy spaces when the amount of fluid drainage is less than 200 ml in 24 hours. The great majority of our patients require drainage for no more than two or three days.
This concerns the paper ”Management of Spontaneous Pneumothorax” by Sibu P. Saha, M.D., and associates (Ann Thorac Surg 19:561, 1975). The authors are to be complimented for advocating an open thoracotomy more widely for the treatment of spontaneous pneuniothorax. However, we prefer a transaxillary thoracotomy with an incision in the second or third interspace since most of the disease is limited to the apex in the majority of these patients. This a p proach, combined with use of the autostapler device, simplifies the surgical procedure and minimizes postoperative discomfort to the patient compared with a standard thoracotomy.
Dnzlid V . Pecorn, M . D . Surgical Service Veternns Administrntion Center 1601 Kirkwood Hwy Wilmington, DE 19805
85
1. Reddy Penagnlirrir, M . D . 208 NW 2nd S t Mineral Wells, TX
76067
