P-OGC91 Significance of the number, size and type of drains used for intercostal drainage after oesophagectomy for cancer

Abstract Background Pleural space drainage with intercostal drains (ICD) is performed after oesophagectomy to allow the lung to reinflate, remove excess fluid post-operatively, and signal chyle or enteric content. Enhanced recovery protocols encourage the use of the minimum number of drains for the shortest duration to facilitate rapid recovery after surgery. There is wide variability in the type, number and size of drains inserted at operation. This study sought to identify the most effective drain pattern insertion, using the need for respiratory reintervention as the primary end point and secondary outcome of the presence of pleural effusions. Methods All patients undergoing oesophagectomy for cancer in one unit were included between November 2014 and December 2020. The operation performed, drain sizes, sides and type were recorded. Respiratory reintervention was defined as replacement of an ICD, bronchoscopy, pleural aspiration or reintubation. The primary and secondary end points, and potential confounders such as age, histology, pre-operative stage of disease, neoadjuvant therapy, pre-existing lung disease, and anastomotic or chyle leak were recorded. Results The study period encompassed 258 patients who underwent oesophagectomy for cancer. Median age 69 (range 32-82), 211 male, 226 ACA:32 SCC, 224 neoadjuvant therapy, 212 right-sided thoracic operations, 46 left thoracoabdominal approach. Post-operative respiratory reinterventions occurred in 47 patients (18.2%). At least one post-operative pleural effusion was present in 52 patients (20.2%): 9 bilateral; 26 contralateral; 17 ipsilateral to the side of thoracic surgery. 67% of effusions were contralateral to the operated side. The use of two or three ICDs (HR 371683269, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 0.938 [0.422-2.085], p < 0.875), and size 24F compared to 28F drains (HR 0, p < 0.999) are not significantly associated with post-operative respiratory reinterventions. Similarly, the presence of post-operative pleural effusions is not significantly associated with the use of two or three ICDs (HR 240242843, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 1.505 [0.665-3.405], p < 0.327), and size 24F compared to 28F drains (HR 1.055 [0.109-10.2], p < 0.963). Conclusions This study supports the use of contralateral pleural space drainage as two thirds of effusions were contralateral to the operated side. It shows no correlation between the size of drains, number of drains or use of Blakes drains and the likelihood of requiring a post-operative respiratory intervention or development of post-operative pleural effusion. Therefore the ERAS principles of the fewest number of drains for the shortest duration should be adopted.

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Pleurodesis with Iodized Talc for Malignant Effusions Using Pigtail Catheters

Annals of Pharmacotherapy ◽

10.1345/aph.17435 ◽

1998 ◽

Vol 32 (7-8) ◽

pp. 739-742 ◽

Cited By ~ 14

Author(s):

Robert L Thompson ◽

Jonathan C Yau ◽

Ronald F Donnelly ◽

Debra J Gowan ◽

Frederick RK Matzinger

Keyword(s):

Pleural Effusion ◽

Tertiary Care ◽

Pleural Space ◽

Pigtail Catheter ◽

Pleural Effusions ◽

Talc Pleurodesis ◽

Malignant Pleural Effusions ◽

Kaplan Meier ◽

A Prospective Study ◽

The Cost

OBJECTIVE: To assess the efficacy of using an iodized talc slurry as a sclerosing agent instilled into the pleural space via a 12-French pigtail catheter for controlling malignant pleural effusions. DESIGN: A prospective study in which patients were followed until their death. SETTING: A university-affiliated tertiary-care teaching hospital. PATIENTS: Medical oncology patients admitted with symptomatic malignant pleural effusions were considered for iodized talc pleurodesis. MAIN OUTCOME MEASURES: The control of pleural effusion. Treatment failure was defined as any reaccumulation of fluid in the pleural space. RESULTS: Fifteen patients were treated for a total of 17 instillations. The median follow-up on all patients until death was 6 months (range 1–20). The most frequent adverse effect in the study group was pleuritic chest pain (60%). The probability of control of effusion, as determined by the method of Kaplan–Meier, was 81% (SEM 9.7%). The cost of preparing 5 g of iodized talc was $4.32 (US). CONCLUSIONS: Iodized talc slurry instilled through a small-bore pigtail catheter is a safe, economical, and effective treatment for malignant pleural effusion.

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Investigation of Pleural Effusions

Acute Medicine Journal ◽

10.52964/amja.0517 ◽

2011 ◽

Vol 10 (4) ◽

pp. 216-220

Author(s):

Luaie Idris ◽

◽

Nilushi Ranaweera ◽

Diane Laws ◽

◽

...

Keyword(s):

Pleural Effusion ◽

Organ Dysfunction ◽

Medical Condition ◽

Pleural Space ◽

Pleural Effusions ◽

Common Medical Condition

Pleural effusion is a common medical condition which often presents on the AMU. There are more than 50 recognised causes of pleural effusion which include diseases local to the pleura or underlying lung, systemic conditions, organ dysfunction and drugs.1 The normal pleural space contains approximately 1mL of fluid. The balance between hydrostatic and oncotic pressures in the visceral and parietal pleural vessels maintains this environment; any disorder affecting this balance will result in a pleural effusion.

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Management of pleural effusion and haemothorax

10.1093/med/9780199600830.003.0125 ◽

2016 ◽

Cited By ~ 1

Author(s):

Davide Chiumello ◽

Silvia Coppola

Keyword(s):

Pleural Effusion ◽

Symptomatic Relief ◽

Underlying Disease ◽

Pleural Space ◽

Bacterial Invasion ◽

Pleural Effusions ◽

Management Options ◽

External Drainage ◽

Malignant Effusions ◽

Pleural Catheter

The main goal of management of pleural effusion is to provide symptomatic relief removing fluid from the pleural space. The options depend on type, stage, and underlying disease. The first diagnostic instrument is the chest radiography, while ultrasound can be very useful to guide thoracentesis. Pleural effusion can be a transudate or an exudate. Generally, a transudate is uncomplicated effusion treated by medical therapy, while an exudative effusion is considered complicated effusion and should be managed by drainage. Refractory non-malignant effusions can be transudative (congestive heart failure, cirrhosis, nephrosis) or exudative (pancreatitis, connective tissue disease, endocrine dysfunction), and the management options include repeated therapeutic thoracentesis, in-dwelling pleural catheter for intermittent external drainage, pleuroperitoneal shunts for internal drainage, or surgical pleurectomy. Parapneumonic pleural effusions can be classified as complicated when there is persistent bacterial invasion of the pleural space, uncomplicated and empyema with specific indications for pleural fluid drainage. Malignancy is the most common cause of exudative pleural effusions in patients aged >60 years and the decision to treat depends upon the presence of symptoms and the underlying tumour type. Options include in-dwelling pleural catheter drainage, pleurodesis, pleurectomy, and pleuroperitoneal shunt. Haemothorax needs to be differentiated from a haemorrhagic pleural effusion and, when suspected, the essential management is intercostal drainage. It achieves two objectives to drain the pleural space allowing expansion of the lung and to allow assessment of rates of blood loss to evaluate the need for emergency or urgent thoracotomy.

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Managing Pleural Disease in Acute Medicine (I): Pleural Effusion

Acute Medicine Journal ◽

10.52964/amja.0176 ◽

2007 ◽

Vol 6 (3) ◽

pp. 114-120

Author(s):

Nazir I. Lone ◽

◽

George Antunes ◽

Keyword(s):

Clinical Practice ◽

Pleural Effusion ◽

Pleural Space ◽

Diagnostic Approach ◽

Initial Assessment ◽

Common Finding ◽

Pleural Disease ◽

Pleural Effusions ◽

Acute Medicine ◽

Recent Developments

A pleural effusion is the accumulation of fluid in the pleural space. It is a relatively common finding in clinical practice. The diagnostic approach to the patient presenting with a pleural effusion is aimed at defining the effusion as a transudate or an exudate. This review summarises the initial assessment and investigation of pleural effusions diagnosed during the acute medical take, and who should be referred for specialist advice. In addition, recent developments, including the measurement of NT-proBNP levels and diagnostic markers for mesothelioma, are presented.

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Pleural effusion

Emergencies in Respiratory Medicine ◽

10.1093/med/9780199202447.003.0024 ◽

2007 ◽

pp. 145-152

Keyword(s):

Pleural Effusion ◽

Pleural Fluid ◽

Chest Radiograph ◽

Pleural Space ◽

Parietal Pleura ◽

Clinical Approach ◽

Clinical Scenario ◽

Pleural Effusions ◽

Wide Range

Introduction 146 Causes 146 Clinical approach 147 Pleural fluid 149 Management 151 Pleural effusions are a common clinical scenario with a wide range of causes. They are defined as an accumulation of fluid between the visceral and parietal pleura. There is normally around 20 ml of fluid present in the pleural space. Around 400 ml needs to be present before clinically apparent, whilst >200 ml is visible on the PA chest radiograph....

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Novel pleural-bladder pump in malignant pleural effusions: from animal model to man

Thorax ◽

10.1136/thoraxjnl-2019-214003 ◽

2020 ◽

Vol 75 (5) ◽

pp. 432-434 ◽

Cited By ~ 4

Author(s):

Philippe Astoul ◽

Sophie Laroumagne ◽

Jeroen Capel ◽

Nicholas A Maskell

Keyword(s):

Quality Of Life ◽

Animal Model ◽

Pleural Effusion ◽

Management Strategy ◽

Malignant Pleural Effusion ◽

Pleural Space ◽

Optimal Management ◽

Pleural Effusions ◽

Pump System

Malignant pleural effusion is common and causes disabling symptoms such as breathlessness. Treatments are palliative and centred around improving symptoms and quality of life but an optimal management strategy is yet to be universally agreed. A novel pump system, allowing fluid to be moved from the pleural space to the urinary bladder, may have a role for the management of recurrent malignant pleural effusion. We hereby describe the first animal study using this device and the results of the first application in patients.

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Pathophysiology and causes of haemoptysis

10.1093/med/9780199600830.003.0126 ◽

2016 ◽

Author(s):

Francesco Blasi ◽

Paolo Tarsia

Keyword(s):

Pleural Effusion ◽

Symptomatic Relief ◽

Underlying Disease ◽

Pleural Space ◽

Bacterial Invasion ◽

Pleural Effusions ◽

Management Options ◽

Indwelling Pleural Catheter ◽

Malignant Effusions ◽

Pleural Catheter

The main goal of management of pleural effusion is to provide symptomatic relief removing fluid from pleural space and the options depend on type, stage and underlying disease. The first diagnostic instrument is the chest radiography while ultrasound can be very useful to guide thoracentesis. Pleural effusion can be a transudate or an exudate. Generally a transudate is uncomplicated effusion treated by medical therapy, while an exudative effusion is considered complicated effusion and should be managed by drainage. Refractory non-malignant effusions can be transudative (congestive heart failure, cirrhosis, nephrosis) or exudative (pancreatitis, connective tissue disease, endocrine dysfunction), and the management options include repeated therapeutic thoracentesis, indwelling pleural catheter for intermittent external drainage, pleuroperitoneal shunts for internal drainage, or surgical pleurectomy. Parapneumonic pleural effusions can be divided in complicated when there is persistent bacterial invasion of the pleural space, uncomplicated and empyema with specific indications for pleural fluid drainage. Malignancy is the most common cause of exudative pleural effusions in patients aged >60 years and the decision to treat depends upon the presence of symptoms and the underlying tumour type. Options include indwelling pleural catheter drainage, pleurodesis, pleurectomy and pleuroperitoneal shunt. Hemothorax needs to be differentiated from a haemorrhagic pleural effusion and when is suspected the essential management is the intercostal drainage. It achieves two objectives to drain the pleural space allowing expansion of the lung and to allow assessment of rates of blood loss to evaluate the need for emergency or urgent thoracotomy.

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Pleural Effusions: Pathophysiology and Management with Intrapleural Tetracycline

Drug Intelligence & Clinical Pharmacy ◽

10.1177/106002808802200102 ◽

1988 ◽

Vol 22 (1) ◽

pp. 15-20 ◽

Cited By ~ 8

Author(s):

Michael A. Oszko

Keyword(s):

Side Effects ◽

Pleural Effusion ◽

Low Cost ◽

Pleural Space ◽

Pleural Effusions ◽

First Line ◽

Disease States ◽

Ready Availability ◽

Low Toxicity

Chronic or recurrent pleural effusions are a consequence of a variety of disease states and may produce significant pain or discomfort in a patient. Both surgical and pharmacological attempts to control pleural effusions have been tried, with moderate success. This article reviews the pathophysiology of pleural effusion and the role of intrapleural tetracycline in its management. Irritating chemicals, when instilled into the pleural space, are known to produce adhesion of the pleural membranes. Tetracycline has been shown in both animal and human studies to be effective in preventing the recurrence of a pleural effusion while producing only minor side effects, such as fever and pleuritic pain. Studies involving tetracycline in treating pleural effusions are reviewed, and guidelines for the preparation and administration of intrapleural tetracycline are presented. Because of its efficacy, low toxicity, ease of preparation, ready availability, and low cost, tetracycline deserves strong consideration as a first-line agent in the management of recurrent pleural effusions.

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Comparison of Heffner Criteria and Light Criteria in Differentiating Exudative and Transudative Pleural Effusion

Nepal Medical College Journal ◽

10.3126/nmcj.v22i3.32638 ◽

2020 ◽

Vol 22 (3) ◽

pp. 141-145

Author(s):

Krishna Chandra Devkota ◽

S Hamal ◽

PP Panta

Keyword(s):

Pleural Effusion ◽

Cross Sectional Study ◽

Pleural Space ◽

Sectional Study ◽

Inclusion Criteria ◽

Cross Sectional ◽

Medical College ◽

The Common ◽

The Mean ◽

Exudative Pleural Effusion

Pleural effusion is present when there is >15ml of fluid is accumulated in the pleural space. It can be divided into two types; exudative and transudative pleural effusion. Tuberculosis and parapneumonic effusion are the common cause of exudative pleural effusion whereas heart failure accounts for most of the cases of transudative pleural effusion. This study was a hospital based cross sectional study performed at Nepal Medical College during the period of January 2016-December 2016. A total of 50 patients who fulfilled the inclusion criteria were enrolled. Pleural effusion was confirmed by clinical examination and radiology. After confirmation of pleural effusion, pleural fluid was aspirated and was analysed for protein, LDH, cholesterol. The Heffner criteria was compared with Light criteria to classify exudative or transudative pleural effusion. Among 50 patients, 30 were male and 20 were female. The mean age of patient was 45.4±21.85 years. The sensitivity and specificity of using Light criteria to detect the two type of pleural effusion was 100% and 90.9%, whereas using Heffner criteria was 94.87%, 100% respectively(P<0.01). There are variety of causes for development of pleural effusion and no one criteria is definite to differentiate between exudative or transudative effusion. In this study Light criteria was more sensitive whereas Heffner criteria was more specific to classify exudative pleural effusion. Hence a combination of criteria might be useful in case where there is difficulty to identify the cause of pleural effusion.

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CLINICAL SYMPTOMS, BIOCHEMISTRY AND CYTOLOGY OF PLEURAL, PERITONEAL EFFUSIONS

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2015.6.10 ◽

2016 ◽

pp. 66-71

Author(s):

Van Mao Nguyen ◽

Huyen Quynh Trang Pham

Keyword(s):

Pleural Effusion ◽

Clinical Symptoms ◽

Cross Sectional Study ◽

Malignant Cells ◽

Sectional Study ◽

Pleural Effusions ◽

Cross Sectional ◽

Breath Sounds ◽

Peritoneal Effusion ◽

Neutrophil Leukocytes

Background: The cytology and the support of clinical symptoms, biochemistry for diagnosis of the cases of effusions are very important. Objectives: - To describe some of clinical symptoms and biochemistry of effusions. - To compare the results between cytology and biochemistry by the causes of pleural, peritoneal fluids. Material & Method: A cross-sectional study to describe all of 47 patients with pleural, peritoneal effusions examinated by cytology in the Hospital of Hue University of Medicine and Pharmacy from April 2013 to January 2014. Results: In 47 cases with effusions, pleural effusion accounting for 55.32%, following peritoneal effusions 29.79% and 14.89% with both of them. The most common symptoms in patients with pleural effusions were diminished or absent tactile fremitus, dull percussion, diminished or absent breath sounds (100%), in patients with peritoneal effusions was ascites (95.24%). 100% cases with pleural effusions, 50% cases with peritoneal effusions and 80% cases with pleural and peritoneal effusions were exudates. The percentage of malignant cells in patients with pleural effusions was 26.92%, in peritoneal effusions was 28.57%, in pleural and peritoneal effusions was 42.86%. The percentage of detecting the malignant cells in patients with suspected cancer in the first test was 57.14%, in the second was 9.53% and 33.33% undetectable. Most of cases which had malignant cells and inflammatory were exudates, all of the cases which had a few cells were transudates. Besides, 7.5% cases which had high neutrophil leukocytes were transudates. Conclusion: Cytology should be carry out adding to the clinical examinations and biochemistry tests to have an exact diagnosis, especially for the malignant ones. For the case with suspected cancer, we should repeat cytology test one more time to increase the ability to detect malignant cells. Key words: Effusion, pleural effusion, peritoneal effusion, cytology, biochemistry

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