Is an Intercostal Chest Drain Necessary After Video-Assisted Thoracoscopic (VATS) Lung Biopsy?

Is an Intercostal Chest Drain Necessary After Video-Assisted Thoracoscopic (VATS) Lung Biopsy?

Heyman Luckraz, FRCS, Kandadai S. Rammohan, FRCS, Mabel Phillips, RGN, Rob Abel, FRCA, Siva Karthikeyan, FRCA, Nihal E. P. Kulatilake, FRCS, and Peter...

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Heyman Luckraz, FRCS, Kandadai S. Rammohan, FRCS, Mabel Phillips, RGN, Rob Abel, FRCA, Siva Karthikeyan, FRCA, Nihal E. P. Kulatilake, FRCS, and Peter A. O’Keefe, FRCS (CTh) Department of Anaesthesiology, and Cardiothoracic Unit, University Hospital of Wales, Cardiff, United Kingdom

Background. Video-assisted thoracoscopic surgical lung biopsy is a frequently performed procedure as an integral part of the diagnostic armamentarium for parenchymal lung disease. However, there is no evidence in the literature concerning the need for an intercostal chest drain after the procedure. Methods. A prospective randomized control trial was set up to assess the need for intercostal chest drainage after video-assisted thoracoscopic surgical lung biopsy. Patients who did not have any air leak after the procedure (lung tested while patient was still under anesthetic) was randomized to either having a chest drain or not. The study was powered at 0.9 using an alpha of 0.01. Results. Thirty patients were recruited in each group. There were no significant differences between the two groups in terms of patients’ age (mean age, 59 versus 54 years), sex, history of steroid use, immediate postoperative pain scores, and wound complications. No signif-

icant pneumothoraces occurred in either group. However in the immediate postoperative phase, 28% and 15% of patients with and without chest drains, respectively, had a small (clinically not significant) pneumothorax (size <10%) on their chest radiograph. Moreover, there was significantly increased in-hospital stay in the chest drain group (median, 3 days versus 1 day; p < 0.001). At 6 weeks’ follow-up, all patients had fully expanded lungs bilaterally. Conclusions. There is no need for an intercostal chest drain in patients undergoing video-assisted thoracoscopic surgical lung biopsy if no air leak is identified at the time of surgery. Patients without a drain are discharged home within 24 hours postoperatively, raising the possibility of this procedure being an outpatient procedure. (Ann Thorac Surg 2007;84:237–9) © 2007 by The Society of Thoracic Surgeons

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Secondary end points were wound complication, patient’s comfort, and aesthetic result of the wound. The study was powered at 0.9 using an alpha of 0.01 and with 30 patients for each group. This study was approved by both the institutional Research and Development Unit and the Local Ethics Research Committee. Patients undergoing VATS lung biopsy were recruited preoperatively and gave written consent to be part of the study. Preoperative variables included age, sex, history of diabetes, steroid use, and side of VATS lung biopsy, whereas postoperative variables included incidence and size of pneumothorax on the postoperative chest radiograph immediately and 24 hours postoperatively, before hospital discharge, and at 6 weeks’ follow-up; the incidence of clinically significant pneumothorax requiring intercostal chest drain insertion; analgesic requirement; patients’ comfort as assessed by a visual analog pain scale; wound complication as assessed by the ASEPSIS (Additional treatment, Serous discharge, Erythema, Purulent exudates, Separation of deep tissues, Isolation of bacteria, Stay as patient prolonged over 14 days) score [2]; and in-hospital length of stay. Video-assisted thoracoscopic surgical lung biopsy was performed using a three-port VATS incision. The biopsy

ideo-assisted thoracoscopic surgery (VATS) is a well-established technique for lung biopsy. It is safe, causes minimal discomfort for patients postoperatively, and offers a good cosmetic result [1]. Traditionally, an intercostal chest drain has been used after VATS lung biopsy without assessing the air leak from the biopsied site. However, in our practice, the majority of patients do not have an air leak after this procedure. Thus, we investigated the need for using a chest drain after VATS lung biopsy.

Patients and Methods Patients undergoing VATS lung biopsy were recruited to a randomized control trial to assess the need for an intercostal chest drain after the VATS lung biopsy. The primary end points were the incidence of clinically significant pneumothorax and the in-hospital length of stay. Accepted for publication March 2, 2007. Presented at the Poster Session of the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29 –31 2007. Address correspondence to Dr Luckraz, Cardiothoracic Unit, Block C5, University Hospital of Wales, Cardiff, CF14 4XW, United Kingdom; e-mail: [email protected]

© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc

0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2007.03.007

GENERAL THORACIC

Is an Intercostal Chest Drain Necessary After Video-Assisted Thoracoscopic (VATS) Lung Biopsy?

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LUCKRAZ ET AL CHEST DRAIN AFTER VATS LUNG BIOPSY

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was carried out using the Roticulator stapling system (Endo GIA [Autosuture, Tyco Healthcare, Norwalk, CT]). Intraoperatively, after performing the VATS lung biopsy and before port site closure, the lung was tested for an air leak by using a size 8 mm Ryles nasogastric tube, inserted within the pleural cavity through the posterior port site with the other end positioned under water within a sterile container. The anesthetist then delivered sustained lung inflation to an airway pressure of 20 cm H2O through the double-lumen tube. All the air within the pleural space was thus evacuated. The nasogastric tube was then removed from the pleural space once the air leak stopped. If no air leak was demonstrated, then the patient was randomized to either having an intercostal chest drain (group A) or not (group B). The randomization process was done using a sealed envelope system. If the randomization indicated the usage of a drain, then an intercostal chest drain was positioned through the anterior VATS port site. If the randomization indicated no drain usage, then no drain was inserted and the VATS port sites were closed using Steri-Strips. If there was a persistent air leak while testing with the nasogastric tube, then the patient was not recruited in the study and an intercostal chest drain was positioned before VATS port closure, as would have been the recommended practice. Seventy patients were approached, and 66 of them consented to be part of the study. Six of them had air leaks when the biopsied lung was tested perioperatively and were thus not randomized in the study. There was complete follow-up for all patients. The decision for patient’s discharge from hospital was made by the junior staff looking after the patient and was based on the following general principles: For the drain group, the drain had to be removed before discharge. The chest radiograph, after drain removal, should be satisfactory. A small pneumothorax (size ⬍10%) was acceptable and patients’ discharge was not deferred. The patient should be comfortable both at rest and on mobilization. The patient should have successfully managed a flight of stairs under physiotherapist assessment. All patients in the drain group had their chest drain removed the day after surgery. No patients required Table 1. Preoperative Data of Patients Variable Mean age (SD), years Male (%) Right side biopsy (%) No steroid usage (%)

Group Aa (n ⫽ 30)

Group Ba (n ⫽ 30)

p Value

54 (13) 65 45 100

59 (10.9) 59 56 87

0.34 0.63 0.42 0.19

a Group A consists of patients randomly assigned to receive an intercostal chest drain; group B consists of patients who did not receive a chest drain.

SD ⫽ standard deviation.

Table 2. Postoperative Data of Patients Variable

Group Aa (n ⫽ 30)

Group Ba (n ⫽ 30)

p Value

Day 1 pain scoreb 5 (4.00, 8.75) 5 (3.75, 7.25) 0.81 Pneumothorax (size ⬍ 10%) Immediately 28 15 0.24 postoperatively (%) Before hospital discharge 31 4 ⬍0.01 (%) At follow-up (%) 0 0 0.99 Length of stayb 3 (2, 4) 1 (1, 2) ⬍0.01 a Group A consists of patients randomly assigned to receive an intercostal chest drain; group B consists of patients who did not receive a chest b drain. Data expressed as median (interquartile range).

drain insertion in the postoperative phase for pneumothorax problem. Patients stayed additional days as a result of discomfort requiring strong intravenous analgesia to achieve comfort for mobilization. This study could not be blinded for obvious reasons. However, to minimize bias, we included a nonthoracic experienced nurse (M.P.) as an external assessor. Her contribution in the trial was to collect the visual analog pain scale score from the patients and assess the port sites using the ASEPSIS score. Our group of radiologists reported the chest radiographs as part of their daily workload, and they were unaware of whether the chest radiograph belonged to a patient in the trial or not.

Results Each group had 30 patients. The preoperative demographics are shown in Table 1. There were no significant differences between the two groups in terms of patients’ age, sex, history of diabetes, and steroid use. There were also no significant differences in terms of immediate postoperative pain scores and wound complications. No significant pneumothoraces occurred in either group. In the immediate postoperative phase just before hospital discharge, 28% and 15% of patients in groups with and without chest drains, respectively, had a small and clinically insignificant pneumothorax (size ⬍10%) on their chest radiograph. No patients in either group developed breathing problems postoperatively. There were no hemodynamic compromises either. Hence, clinically patients had insignificant pneumothoraces. Moreover, there was significantly increased inhospital stay in the chest drain group (median, 3 days versus 1 day; p ⬍ 0.001). Most patients stayed additional days, even after the drain was removed (the day after surgery), because of discomfort. Although the median pain score was the same for both groups, the interquartile range was much broader with higher scores for the drain group as shown in Table 2. The patients with higher visual analog pain scale scores required intravenous opioid-based analgesia and thus were not ready for discharge until they were comfortable on oral analgesics (paracetamol, diclofenac sodium [Voltarol], or tramadol).

At 6 weeks’ follow-up, all the patients had fully expanded lungs bilaterally. Table 2 illustrates the postoperative data for the two groups. The final histologic diagnosis was as follows: in the no-drain group—non-specific interstitial pneumonitis (12 patients), usual interstitial pneumonia (5 patients), sarcoid (4 patients), emphysema (2 patients), extrinsic allergic alveolitis (2 patients), and bronchiolitis obliterans organizing pneumonia, collagen vascular disease, lymphoproliferative process, hamartoma, and Langerhans cell histiocytosis (1 patient each); in the drain group— usual interstitial pneumonia (7 patients), non-specific interstitial pneumonia (6 patients), emphysema (4 patients), adenocarcinoma (3 patients), extrinsic allergic alveolitis (2 patients), bronchiolitis obliterans organizing pneumonia (2 patients), respiratory bronchiolitis– associated interstitial lung disease (2 patients), and amiodarone-induced fibrosis, rheumatoid disease, sarcoidosis, and Wegener’s granulomatosis (1 patient each).

Comment The need for intercostal chest drain after VATS lung biopsy is not evidence based. This study evaluated the need of using an intercostal chest drain after VATS lung biopsy and demonstrated that, in fact, an intercostal chest drain is not necessary in most patients. Watanabe and coworkers [3], in their observational study in 2004, concluded that the lack of placement of an intercostal chest drain was not associated with increased morbidity in a carefully selected group of patients. Based on our study, this group can now be defined as those who do not demonstrate an air leak after lung biopsy using the technique described above. Moreover, there was not an increase in the incidence of clinically significant complications postoperatively between the groups with and without a chest drain. Thus, appropriately selected patients are not at increased risk of complications. These findings provide the opportunity of performing this procedure as an outpatient procedure. Several authors have now investigated this policy [4 – 6]. However, although they advocated an outpatient procedure, they did not assess for air leak after lung biopsy and thus all their patients had an intercostal chest drain inserted. The drain was then removed a few hours after the procedure

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before the patient’s discharge from the hospital. This further confirms that in most patients, when there is no air leak, a chest drain is not required. Blewett and colleagues [7] reported on their experience with an outpatient procedure. They, just as we suggested, tested the biopsied lung for air leak before deciding on the usage of an intercostal chest drain. However, they performed open lung biopsy and also inspected the cut surface for air-leak intraoperatively, a procedure that is difficult to perform under direct vision during VATS. The economics of this practice has enormous implications. Molins and associates [6] reviewed the cost savings by their outpatient thoracic practice. This included patients undergoing VATS mediastinoscopy, lung biopsy, and bilateral thoracic sympathectomy. In their practice, patients were discharged within 6 hours of the general anesthetic, allowing a hospital total stay saving of nearly $300 per patient. Video-assisted thoracoscopic surgical lung biopsy without the need of an intercostal chest drain is a safe procedure in well-selected patients. This reduces the discomfort experienced by patients when an intercostal chest drain is inserted and allows for the procedure to be an outpatient procedure with significant cost savings.

References 1. Ayed AK, Raghunathan R. Thoracoscopy versus open lung biopsy in the diagnosis of interstitial lung disease: a randomised controlled trial. J R Coll Surg Edinb 2000;45:159 – 63. 2. Luckraz H, Treasure T. Infections in cardiac surgery. Curr Opin Surg Infect 1996;4:1– 4. 3. Watanabe A, Watanabe T, Ohsawa H, et al. Avoiding chest tube placement after video-assisted thoracoscopic wedge resection of the lung. Eur J Cardiothorac Surg 2004;25:872– 6. 4. Chang AC, Yee J, Orringer MB, Iannettoni MD. Diagnostic thoracoscopic lung biopsy: an outpatient experience. Ann Thorac Surg 2002;74:1942– 6. 5. Russo L, Wiechmann RJ, Magovern JA, et al. Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Ann Thorac Surg 1998;66:1751– 4. 6. Molins L, Fibla JJ, Perez J, Sierra A, Vidal G, Simon C. Outpatient thoracic surgical programme in 300 patients: clinical results and economic impact. Eur J Cardiothorac Surg 2006;29:271–5. 7. Blewett CJ, Bennett WF, Miller JD, Urschel JD. Open lung biopsy as an outpatient procedure. Ann Thorac Surg 2001;71: 1113–5.

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Ann Thorac Surg 2007;84:237–9