Early Chest Tube Removal After Thoracoscopic Esophagectomy with High Output

Abstract

Background:

The optimal volume threshold for removal of chest tubes after thoracic surgery has not been determined. The purpose of the study was to assess the new volume threshold for chest tube removal after thoracoscopic esophagectomy (TSE).

Materials and Methods:

A retrospective study was conducted with a prospective database. All patients underwent TSE. Eligible patients were divided into two groups: Group A had their chest tubes removed at a drainage volume of 150 mL/day or less, whereas Group B had their chest tubes removed at a drainage volume of 300 mL/day or less. Chest drainage time, volume of drainage on postoperative day (POD) 1 and 2, postoperative hospital stay, postoperative complications, and the incidence of invasive re-intervention were evaluated.

Results:

In total, 70 patients were included, with 32 patients in Group A and 38 patients in Group B. The mean chest drainage time in Group B was significantly shorter than that in Group A (2.6 ± 0.8 versus 4.0 ± 1.0 days, P < .001). There were no statistically significant differences in volume of drainage on POD 1 and 2, postoperative hospital stay, and postoperative complications between Group A and Group B (P > .05). A total of 4 patients in Group A and 3 patients in Group B developed postoperative pleural effusions requiring thoracentesis (P > .05). No patient was re-admitted because of pleural effusion during the 30-day follow-up period.

Conclusions:

This study showed that a 300 mL/day volume threshold for chest tube removal after TSE was capable of reducing the postoperative chest drainage time without compromising patient safety.

Introduction

Management of chest tubes directly influences postoperative satisfaction in patients who are otherwise making a recovery following esophagectomy. In our hospital chest tubes were previously removed at a drainage volume of <150 mL/day. Since 2014 this criterion was changed as chest tubes were allowed to be removed at a drainage volume of <300 mL/day, if no contraindication was identified. The incentive for this new volume threshold of chest tube removal was based on results from studies indicating that chest tubes induce pain, delay early mobilization of the patient, and increase the risk of infection.^1–3 However, clinical suspicion developed that this change in clinical practice was associated with an increasing number of patients developing postoperative complications requiring re-intervention.

The objective of this study was to evaluate the feasibility and safety of a new volume threshold (300 mL/day) for chest tube removal compared with traditional management (150 mL/day) after thoracoscopic esophagectomy (TSE) for esophageal carcinoma.

Patients and Methods

A retrospective cohort study was performed on a prospective database. Patients who underwent TSE performed by one general thoracic surgeon (J.W.) between August 2012 and November 2014 were studied. All patients were definitively diagnosed with esophageal cancer by preoperative ultrasound endoscopy, barium meal study, and enhanced computed tomography (positron emission tomography, if possible). Patients who had a previous thoracic surgery, massive pleural adhesions (defined as more than half an hour was needed to excise the adhesions), or a postoperative chylothorax (defined as the appearance of milky fluid from thoracic drains after surgery) or who died within 30 days postoperatively were excluded from this study. An informed consent was obtained from all the patients. The study was approved by the Ethics Committee of the hospital.

Finally, 70 patients were included in this study. The patients were divided into two groups. In Group A, patients had their chest tube removed at a drainage volume of <150 mL/day after TSE. In Group B, patients underwent TSE with their chest tube removal at a drainage volume of <300 mL/day.

All patients' medical records were reviewed from the database. Preoperative chemoradiotherapy was not used in any case. The pathologic characteristics, including tumor invasion, node metastasis, and stage, were classified according to the American Joint Committee on Cancer staging manual, 7th edition.⁴

Postoperative complications included respiratory complications (included pneumonia, pleural effusion, and atelectasis confirmed by the preremoval chest x-ray [CXR]), pneumothorax (any visible air on the preremoval CXR between the lung and the chest wall), subcutaneous emphysema (air in the layer under the skin on the chest, neck, and face), and anastomotic leaks. Drainage time (from the day of the operation until the chest tube was removed), postoperative hospital stay (from the day of the operation until the patient was discharged from the hospital), and re-admission (defined as re-admission due or partially due to a pleural effusion within 30 days of the date of discharge) were recorded.

Surgery

All patients were intubated with double-lumen endotracheal tubes and received single-lung ventilation. The patient was placed in the left lateral decubitus position, leaning forward at a 30° angle. A “four-port” approach was adopted: (1) at the midaxillary line in the seventh intercostal space (10 mm; camera port); (2) at the posterior axillary line in the ninth intercostal space (10 mm); (3) at the scapular line in the seventh intercostal space (5 mm); and (4) at the fourth intercostal space in the anterior axillary line (5 mm). The esophagus was mobilized with the paraesophageal lymph nodes in an en bloc maneuver. A 28-French chest tube was placed through the camera port. Thoracic duct ligation was not routinely conducted. The patient was rotated to a supine position. Open laparotomy (8–10 cm) was performed for stomach mobilization and abdominal lymph node dissection. A jejunostomy was conducted at 30 cm from the ligament of Treitz. The conduit was sutured to the mobilized esophagus for tunneling to the neck where an end-to-side esophagogastric anastomosis was performed.

Chest tube protocol

All chest tubes were connected to the same chest drainage system using an underwater seal without external suction, and the volume of drainage was recorded every 6 hours. The criteria for removing the chest tube were established as follows: (1) the volume of drainage was <150 mL/day (Group A) or <300 mL/day (Group B), (2) adequate evacuation of intrathoracic air and fluid (confirmed by preremoval CXR and clinical examination), (3) hemothorax and chylothorax were eliminated (identified by clinical examination and laboratory tests), and (4) chest tubes were observed and evaluated for removal at least 24 hours after the surgery. Chest tubes were removed at the end of inspiration, and the site was covered with an occlusive dressing including petroleum gauze. All patients underwent clinical reassessment examination 4 hours after the chest tube removal. A postremoval CXR was not routinely conducted.

Postoperative management

All patients in this study received similar postoperative care. On postoperative day (POD) 1, patients were encouraged to move out of bed, and enteral nutrition was given through the jejunostomy feeding tube. Chest tubes were observed at least twice every day, and attending surgeons made the decision on chest tube removal. However, all patients did not have their chest tubes removed in the first 24 hours after the surgery even if they had a low volume of drainage. The character of the drainage was evaluated every 24 hours. In Group A, if the drainage appeared white or milky it was sent for triglyceride content analysis, whereas in Group B, all patients had the level of triglycerides in chest drainage evaluated every 24 hours until the chest tubes were removed. A triglyceride level of 110 mg/dL or greater was considered diagnostic of a chylothorax, and tubes were not removed.⁵ Physical examination was performed every day, and postremoval CXRs were performed when clinically indicated. Patients were eventually discharged home when oral intake was adequate for their nutritional needs. After discharge, the patients were instructed to have routine follow-up at our department. Computed tomography was performed routinely 30 days after the date of discharge. Invasive re-intervention (thoracentesis or chest tube re-insertion) was performed according to the attending surgeon's decision based on the patient's symptoms, physical examination, and CXRs.

Statistical analyses

Continuous data were expressed as mean ± standard deviation values and compared between the two groups by using the independent-samples t test. Categorical data were presented as numbers and percentages and compared by using the chi-squared test and the Mann–Whitney U test. All statistical analyses were carried out with SPSS for Mac software (version 20.0; IBM, Armonk, NY). Differences were considered significant for P < .05 (two-sided).

Results

During the study period, in total, 70 patients were included (Group A, 32 patients; Group B, 38 patients). Patient characteristics are shown in Table 1. There were no intraoperative conversions in the present study. The mean ages of Groups A and B were 64.9 ± 7.2 and 62.7 ± 6.7 years (P = .187), respectively. The pathological analysis included squamous cell carcinoma, adenocarcinoma, and other types. Results showed that there were no statistically significant differences between the two groups (P = .193). There was also no significant difference between the two groups in tumor location (P = .585) or pathologic staging (P = .851). In addition, the two groups were comparable in terms of sex, body mass index, history of smoking, pulmonary function tests, American Society of Anesthesiologists classification, and comorbidities (P > .05).

Table 1.

Baseline Characteristics

	Group A (n = 32)	Group B (n = 38)	P value
Sex [n (%)]			.095
Male	28 (87.5)	27 (71.1)
Female	4 (12.5)	11 (28.9)
Age (years) (mean ± SD)	64.9 ± 7.2	62.7 ± 6.7	.187
Body mass index (kg/m²) (mean ± SD)	22.3 ± 3.4	22.3 ± 3.1	.952
History of smoking [n (%)]	17 (53.1)	14 (36.8)	.172
Pulmonary function tests (mean ± SD)
FEV₁ (% predicted)	90.7 ± 18.6	97.9 ± 17.5	.101
DLCO (% predicted)	78.4 ± 23.9	83.7 ± 22.0	.339
ASA classification [n (%)]			.484
1	3 (9.4)	0 (0)
2	19 (59.4)	32 (84.2)
3	10 (31.3)	6 (15.8)
Type of carcinoma [n (%)]			.193
Squamous cell carcinoma	30 (93.8)	32 (84.2)
Adenocarcinoma	2 (6.3)	3 (7.9)
Other	0 (0)	3 (7.9)
Tumor location [n (%)]			.585
Upper third	5 (15.6)	4 (10.5)
Middle third	24 (75.0)	30 (78.9)
Lower third or gastroesophageal junction	3 (9.4)	4 (10.5)
Comorbidities [n (%)]
HTN	12 (37.5)	8 (21.1)	.129
Diabetes	1 (3.1)	3 (7.9)	.734
COPD	4 (12.5)	3 (7.9)	.810
CAD	3 (9.4)	2 (5.3)	.842
Pathologic staging [n (%)]			.851
IA	4 (12.5)	4 (10.5)
IB	4 (12.5)	6 (15.8)
IIA	3 (9.4)	5 (13.2)
IIB	11 (34.4)	12 (31.6)
IIIA	8 (25.0)	7 (18.4)
IIIB	0 (0)	3 (7.9)
IIIC	2 (6.3)	1 (2.6)

ASA, American Society of Anesthesiologists; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; DLCO, carbon monoxide diffusing capacity; FEV₁, forced expiratory volume in the first second; HTN, hypertension; SD, standard deviation.

Postoperative outcomes are shown in Table 2. The mean chest drainage time was 2.6 ± 0.8 days for Group B. Compared with Group A, patients in Group B had a significantly shorter chest drainage time (P < .001). There was no significant difference between the two groups in volume of drainage on POD 1 and 2 (P = .848 and P = .430, respectively). The postoperative hospital stay in Group B was shorter, but the difference was not significant (P = .706). Respiratory complications were observed in 9 (28.1%) patients in Group A and 6 (15.8%) patients in Group B (P = .210). There was no significant difference in the incidence of pneumothorax between the two groups (12.5% versus 7.9%, P = .810). No clinically significant pneumothorax was identified after chest tube removal in this study. Two (5.3%) subcutaneous emphysemas were observed in Group B; after the exclusion of tracheal injury, both of the chest drainage tubes were removed on POD 3. Four (5.7%) anastomotic leaks were observed in this study (1 patient from Group A and 3 from Group B; 3.1% versus 7.9%, P = .734) and managed by means of local cervical drainage. Among the 7 (10.0%) patients who developed fluid accumulation requiring invasive re-intervention after removal of the chest tubes, 4 (12.5%) were from Group A, and 3 (7.9%) were from Group B (P = .810). All patients were managed with a thoracentesis, and the complication resolved before discharge. None of the patients required re-insertion of the chest tube in this study. During the 30-day follow-up period, no patient was re-admitted because of pleural effusion.

Table 2.

Postoperative Outcomes

	Group A (n = 32)	Group B (n = 38)	P value
Chest drainage time (days) (mean ± SD)	4.0 ± 1.0	2.6 ± 0.8	<.001
Volume of chest drainage (mL) (mean ± SD)
POD 1	355.9 ± 142.1	361.8 ± 114.7	.848
POD 2	265.6 ± 106.4	283.9 ± 86.6	.430
Postoperative hospital stay (days) (mean ± SD)	13.1 ± 6.0	12.6 ± 4.6	.706
Postoperative complications [n (%)]
Respiratory complications	9 (28.1)	6 (15.8)	.210
Pneumothorax	4 (12.5)	3 (7.9)	.810
Subcutaneous emphysema	0 (0)	2 (5.3)	.496
Anastomotic leak	1 (3.1)	3 (7.9)	.734
Thoracentesis	4 (12.5)	3 (7.9)	.810
Re-insertion of chest tube	0 (0)	0 (0)	—
Re-admission	0 (0)	0 (0)	—

POD, postoperative day; SD, standard deviation.

Discussion

Over the past several decades, the protocol for the removal of the chest tube was based primarily on tradition in our department. In recent years several studies on early chest tube removal from the pleural cavity following pulmonary resection and cardiac surgery have been published. Bjerregaard et al.⁶ reported it was safe to remove chest tubes despite drainage of 450 mL/day after lobectomy by video-assisted thoracic surgery. Xie et al.¹ performed a prospective randomized study and found that a 300 mL/day volume threshold for chest tube removal after video-assisted thoracic surgery lobectomy was feasible and safe and that a 450 mL/day volume threshold for chest tube removal increased the risk of thoracentesis. Andreasen et al.⁷ found that early chest tube removal following cardiac surgery was associated with pleural and/or pericardial effusions requiring invasive treatment and abandoned early removal of the chest tubes in their department. The question is, does early chest tube removal protocol (<300 mlL/day) apply to patients who have undergone TSE? For this reason, we decided to evaluate the new volume threshold (<300 mL/day) of chest tube removal for patients who underwent TSE.

Implementing a new volume threshold of early chest tube removal after esophagectomy has demonstrated many advantages. First, patients after esophagectomy suffer from great pain caused by chest tubes; early chest tube removal can reduce postoperative pain and preserve the early postoperative pulmonary function.^8,9 Second, with early removal of the chest tube, patients can allow earlier and more aggressive ambulation, which may decrease the likelihood of complications and decrease the necessity of hospitalization.¹⁰ Third, because the chest tube duration is one of the most important factors influencing the hospital stay and hence costs, the new chest tube removal threshold provide an opportunity to reduce the postoperative cost.^8,11

We have shown in the present study that after thoracoscopic esophageal resection, removal of the chest tube when the daily volume was 300 mL or less was a safe procedure. In addition, it showed that the new threshold was associated with a shorter chest drainage time. However, this did not lead to a shorter postoperative hospital stay. Interestingly, this finding was directly opposite to our opinion that short chest drainage time might be associated with better recovery and shorter postoperative hospital stay. This may be explained by the postoperative management protocol of our department. In our department, patients were not discharged until oral intake met their nutritional needs. The postoperative hospital stay mainly depended on what time oral intake was begun. Even though Group B showed a shorter drainage time, however, there was no significant difference between the two groups in postoperative hospital stay.

During the procedure of introducing the new volume threshold of chest tube removal, two measures were enforced. First, the chest tube would not be removed in the first 24 hours after the surgery, even with a drainage volume of <300 mL/day. One danger of early chest tube removal is accidental bleeding from the proper esophageal artery or from the esophageal bed. In our department the character and volume of the drainage should be evaluated at least 24 hours after surgery for possible life-threatening bleeding. Postoperative hemorrhage is very rarely seen after the first 24 hours.¹² Another advantage of keeping the chest immobile for 24 hours was early diagnosis of chylothorax. Chyle production occurs in the small intestine following metabolism of ingested long-chain triglycerides.¹³ Also, postoperative administration of cream to patients suffering from chylothorax to facilitate the diagnosis is well recorded.¹⁴ For all patients in this study, enteral nutrition that contained long-chain triglycerides was given through the jejunostomy feeding tube in the first 24 hours after the surgery, which made it easier to identify the chylothorax.¹⁵

Second, before making the decision to remove a chest tube, the character of the drainage should be evaluated. In Group B, all patients had the level of triglycerides in chest drainage evaluated before chest tube removal. A drainage triglyceride level of greater than 110 mg/dL is highly suggestive of a chylothorax, and the patient would only have parenteral nutrition with the chest tube kept in place.¹³ Besides hemothorax or chylothorax, cerebral–arachnoid pleural fistula needed to be considered, which was a much less common cause of a high chest tube output as patients always had symptoms of headache, nausea, and confusion.⁵

When these two measures were implemented, a 300 mL/day drainage might not be a contraindication to remove the chest tube after TSE.

Subcutaneous emphysema after esophagectomy is not a common complication. In this study 2 cases of subcutaneous emphysema were observed on POD 1 in Group B. The 2 patients presented subcutaneous crepitations of the face and neck. However, there was no drop in saturation and no air leaking from chest tube. Diagnosis was confirmed by computed tomography on POD 2, which revealed pneumomediastinum and subcutaneous emphysema. However, large pneumothorax (defined as a 3-cm distance from the outer edge of the pleural space to the most apical portion of the collapsed lung) was not found, which might coexist with subcutaneous crepitations.^14,15 After a careful review of the surgical videos and an appropriate clinical examination, tracheal injuries were excluded. Both patients had chest tubes removed on POD 3, and the postoperative courses were uneventful.

After reviewing surgical videos of the 2 patients, we found that there were enlarged lymph nodes along the right-side recurrent laryngeal nerve (metastasis confirmed by postoperative pathology). After dissection of the right-side recurrent laryngeal nerve lymph nodes and the surrounding lymphatic tissue, a large “tunnel” was left between the upper esophagus and the outlet of the thoracic cavity. In our department breathing and coughing exercises were recommended for the possible atelectasis on POD 1.¹⁶ Also, the exercises might force air that left in the thoracic cavity at the end of the operation leak via the large “tunnel,” causing subcutaneous emphysema of the face and neck. This might be the likely explanation of the development of subcutaneous emphysema in our patients.

Based on this finding, a new chest tube management strategy was applied. Chest tubes were placed to suction (−15 cm of H₂O) in the anesthesia recovery room and switched to a water seal when the patient was transferred to the general ward (Fig. 1). We were not able to retrieve information about the new chest tube management strategy in the present study.

FIG. 1.

Algorithm for chest tube management after thoracoscopic esophagectomy. CXR, chest x-ray.

In this study we had successfully implemented the new volume threshold for chest tube removal after TSE. We believe that several factors contributed to this result. First, anastomotic leak is one of the most feared complications of esophagectomy because of its association with high morbidity and mortality.¹⁷ The chest tube has been demonstrated to play an important role in the diagnosis and treatment of intrathoracic anastomotic leak, which always leads to severe mediastinitis.¹⁸ However, a chest tube was not often required in the management of cervical anastomotic leak, which could be diagnosed from the cervical incision and drainage. In this study the new volume threshold for chest tube removal was applied to patients with cervical anastomoses. Second, gauze astriction is a basic hemostatic practice and highly effective.¹⁹ The gastric conduit placed into the posterior mediastinum could stop possible bleeding by acting as “gauze” and reduce the risk of bleeding after the removal of the chest tube. Third, imbalance in hydrostatic and oncotic pressures can lead to fluid accumulation in the pleural space and weaken the great absorptive capacity of the pleura.^20,21 In our department patients who underwent an esophagectomy were given enteral nutrition on POD 1, which made it easier for them to maintain the balance and made it possible to remove the chest tube early.²² In order to obtain satisfactory results, we now routinely use the new volume threshold instead of traditional management for postoperative chest tube removal after TSE.

We acknowledge that this study was limited by its retrospective design, the small number of patients, and short-term follow-up. However, given the above-noted limitations, we believe it to be a useful evaluation of the new 300 mL/day volume threshold for chest tube removal after TSE. To our knowledge, no large, prospective, controlled studies have assessed the effects of treating patents after TSE with the 300 mL/day volume threshold for chest tube removal.

Conclusions

In conclusion, the new volume threshold (300 mL/day) for chest tube removal after TSE is both safe and feasible. Our data support the proposal that a 300 mL/day volume threshold for chest tube removal after TSE does not compromise patient care and may lead to a significant reduction of chest drainage time. Further investigation via a randomized controlled trial is warranted to establish the utility of this new volume threshold for widespread use.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Xie

, Xu

, Tang

, et al. A prospective randomized, controlled trial deems a drainage of 300 ml/day safe before removal of the last chest drain after video-assisted thoracoscopic surgery lobectomy. Interact Cardiovasc Thorac Surg, 2015; 21:200–205.

Utter

. The rate of pleural fluid drainage as criterion for the timing of chest tube removal: Theoretical and practical considerations. Ann Thorac Surg, 2013; 96:2262–2267.

Okur

, Baysungur

, Tezel

, et al. Comparison of the single or double chest tube applications after pulmonary lobectomies. Eur J Cardiothorac Surg, 2009; 35:32–35; discussion 35–36.

Sobin

, Gospodarowicz

, Wittekind

(eds). UICC TNM Classification of Malignant Tumours, 7th ed. Oxford, United Kingdom: Wiley-Blackwell, 2009, pp. 63–72.

Cerfolio

, Bryant

. Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output. J Thorac Cardiovasc Surg, 2008; 135:269–273.

Bjerregaard

, Jensen

, Petersen

, et al. Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day. Eur J Cardiothorac Surg, 2014; 45:241–246.

Andreasen

, Sørensen

, Abrahamsen

, et al. Early chest tube removal following cardiac surgery is associated with pleural and/or pericardial effusions requiring invasive treatment. Eur J Cardiothorac Surg, 2015 February 7 [Epub ahead of print]. doi:10.1093/ejcts/ezv005.

Refai

, Brunelli

, Salati

, et al. The impact of chest tube removal on pain and pulmonary function after pulmonary resection. Eur J Cardiothorac Surg, 2012; 41:820–823.

Ueda

, Tanaka

, Hayashi

, et al. Meshbased pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection. J Surg Res, 2011; 167:e71–e75.

10.

Zhang

, Li

, Hu

, et al. A prospective randomized single-blind control study of volume threshold for chest tube removal following lobectomy. World J Surg, 2014; 38:60–67.

11.

Varela

, Jiménez

, Novoa

, et al. Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy. Eur J Cardiothorac Surg, 2005; 27:329–333.

12.

Göttgens

, Siebenga

, Belgers

, et al. Early removal of the chest tube after complete video-assisted thoracoscopic lobectomies. Eur J Cardiothorac Surg, 2011; 39:575–578.

13.

Yadav

, Nolan

, Nichols

3rd , et al. Tension chylothorax following pneumonectomy. Respir Med Case Rep, 2014; 14:16–18.

14.

Repanshek

, Ufberg

, Vilke

, et al. Alternative treatments of pneumothorax. J Emerg Med, 2013; 44:457–466.

15.

Staats

, Ellefson

, Budahn

, et al. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc, 1980; 55:700–704.

16.

Yamana

, Takeno

, Hashimoto

, et al. Randomized controlled study to evaluate the efficacy of a preoperative respiratory rehabilitation program to prevent postoperative pulmonary complications after esophagectomy. Dig Surg, 2015; 32:331–337.

17.

Noble

, Curtis

, Harris

, et al. Risk assessment using a novel score to predict anastomotic leak and major complications after oesophageal resection. J Gastrointest Surg, 2012; 16:1083–1095.

18.

Crestanello

, Deschamps

, Cassivi

, et al. Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg, 2005; 129:254–260.

19.

Brill

. Electrosurgery: Principles and practice to reduce risk and maximize efficacy. Obstet Gynecol Clin North Am, 2011, 38:687–702.

20.

Sahn

. Pleural effusions of extravascular origin. Clin Chest Med, 2006; 27:285–308.

21.

Olgac

, Cosgun

, Vayvada

, et al. Low protein content of drainage fluid is a good predictor for earlier chest tube removal after lobectomy. Interact Cardiovasc Thorac Surg, 2014; 19:650–655.

22.

Fujita

, Daiko

, Nishimura

. Early enteral nutrition reduces the rate of life-threatening complications after thoracic esophagectomy in patients with esophageal cancer. Eur Surg Res, 2012; 48:79–84.