Interact CardioVasc Thorac Surg 2009;8:58-61. doi:10.1510/icvts.2008.188086
© 2009 European Association of Cardio-Thoracic Surgery
Institutional report - Thoracic general |
The use of Blake drains following general thoracic surgery: is it an acceptable option?
Hiroshige Nakamura*,
Yuji Taniguchi,
Ken Miwa,
Yoshin Adachi,
Shinji Fujioka and
Tomohiro Haruki
Division of General Thoracic Surgery, Tottori University Hospital, 36-1 Nishi-cho, Yonago, Tottori 683-8504, Japan
Received 11 July 2008;
received in revised form 10 September 2008;
accepted 16 September 2008
*Corresponding author. Tel.: +81 859386737; fax: +81 859386730.
E-mail address: hnaka{at}med.tottori-u.ac.jp (H. Nakamura).
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Abstract
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As a method of chest drainage, we analyzed the extended utility of silastic flexible drains (Blake drains, Ethicon, Inc., Somerville, NJ) for general thoracic surgery. In 420 cases of general thoracic surgery, Blake drains were used. To examine the utility of Blake drains, we investigated the diseases for which they were used, their effectiveness in addressing postoperative complications. The treated diseases for which Blake drains were used comprised 181 cases of primary lung cancer, 44 cases of metastatic lung tumor, 57 cases of benign lung disease, 32 cases of mediastinal tumor, 6 cases of myasthenia gravis, 76 cases of spontaneous pneumothorax, 14 cases of chest wall and/or pleural tumor, 6 cases of empyema, and 4 cases of diaphragmatic disease. Blake drains functioned efficiently in 3 cases of re-operation for postoperative bleeding, 2 cases of adhesion therapy with drugs for persistent air leaks, and 1 case of re-operation for chylothorax. There were no cases of either complications or patient complaints of discomfort resulting from drain placement. The use of Blake drains for general thoracic surgery is considered to be an acceptable option, and it is necessary to proceed with further investigations of larger numbers of cases.
Key Words: Small silastic drain; Blake drains; General thoracic surgery
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1. Introduction
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Chest tubes that are used following general thoracic surgery must provide proper drainage of both airs and fluids and must also reflect the information from the thoracic cavity. These requirements have traditionally been induced with the use of one or two 28–32Fr large bore plastic drains (conventional drains). However, these semi-rigid tubes can cause a patient discomfort and pain, potentially interfering with the patient's deep respiration and causing difficulty expelling sputum and/or atelectasis. In addition, patients often complain of pain during the removal of the drain and delayed wound healing at the drain insertion site. Recently developed silastic flexible drains (Blake drains, Ethicon, Inc., Somerville, NJ) are available in two sizes (19Fr and 24Fr) and are expected to resolve such disadvantages posed by the use of conventional drains, and their utility as mediastinal drains used following cardiac surgery was first reported in 2000 [1]. Subsequently, they have also been used in several cases of thoracic surgery creating further discussion regarding their usefulness [2–6]. We have used 19Fr Blake drains for the majority of 420 cases of general thoracic surgery performed since 2005 and have obtained good results. We discuss whether the use of Blake drains as chest tubes is an acceptable option.
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2. Patients and methods
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We began using Blake drains in November 2005, and by April 2008, they had been used in a total of 420 cases. These cases in which Blake drains were used comprised 264 males and 156 females, and the mean age was 59.8 years (range: 12–89 years). Only one Blake drain was placed for each case. In each case, the drain was inserted through an insertion point on the second or third intercostal anterior axillary line and descended into the dorsal region via the apical portion of the lung to be placed on the diaphragm (Fig. 1). After confirming that there were no air leaks and that the drainage was not bloody, purulent, or milky, the drain was removed and the wound was closed with surgical tape. Fig. 2a and b shows the conditions of a Blake drain during placement and the conditions of the wound after removal. In order to examine the utility of Blake drains, we analyzed the diseases and surgical procedures for which Blake drains were used, the chest tube duration, and the status of wound healing at the drainage site and examined incidences of postoperative complications.
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Fig. 2. Conditions of the 19Fr Blake drain during placement (a) and the wound (arrow) after removal (b).
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3. Results
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The diseases for which Blake drains were used comprised 181 cases of primary lung cancer, 44 cases of metastatic lung tumor, 57 cases of benign lung disease, 32 cases of mediastinal tumor, 6 cases of myasthenia gravis, 76 cases of spontaneous pneumothorax and emphysematous lung disease, 14 cases of chest wall and/or pleural tumor, 6 cases of empyema, and 4 cases of diaphragmatic disease (Table 1). Surgical procedures included 1 case of panleuro-pneumonectomy, 135 cases of lobectomy, 11 cases of segmentectomy, 206 cases of partial lung resection or bullectomy, 36 cases of mediastinal tumor resection, 6 cases of extended thymo-thymectomy, 21 cases of chest wall and/or pleural resection, and 4 cases of diaphragmatic resection, and 61 of these cases underwent open thoracotomy while the remaining 359 cases underwent video-assisted thoracic surgery (Table 2). The types of Blake drains used included 19Fr drains (410 cases) and 24Fr drains (seven cases), and the two drains were used in combination in three cases. The average chest tube duration by surgical procedure was 3.0 days for a panpleuro-pneumonectomy, 2.7 days for a lobectomy, 1.5 days for a partial resection or bullectomy, 2.5 days for a segmentectomy, 1.8 days for mediastinal surgery, 2.7 days for pleural surgery, and 1.3 days for diaphragmatic surgery.
Re-operation was required to treat postoperative bleeding in three cases (0.7%) in which 19Fr Blake drains were used. In our analysis of the amount of bleeding over time from the drains in these cases, the fluid was drained at a uniform rate in all the cases and re-operation was performed when the fluid level reached 500 ml at 1 h after surgery, 400 ml at 2 h after surgery, and 450 ml at 4 h after surgery, respectively (Fig. 3). The sites of bleeding included the trocar insertion site in the chest wall in two cases and the detached adhesion site in one case, and these were managed using 19Fr Blake drains again to obtain a good clinical course. Advanced air leaks were observed in two cases in which a 19Fr Blake drain was used, and because of the occurrence and progression of subcutaneous emphysema, the drain connector was removed on day 5 and day 6, respectively, after surgery and 5KE of OK-432 (group A streptococcus pyogenes of human origin) was injected directly into the thoracic cavity through the Blake drain. The air leaks immediately stopped and the subcutaneous emphysema also improved. After performing a chest X-ray and confirming that lung expansion was good, the drain was removed on day 8 after surgery in both of the cases. Chylothorax developed on day 1 after surgery in one case of mediastinal cyst originating from thoracic duct, but 600 to 1400 ml of milky fluid was discharged daily and a chest X-ray confirmed that the patient had good lung expansion. On day 6 after surgery, re-operation was performed to clip the thoracic duct under thoracoscope and the drain was removed on postoperative day 10.
In the cases in which Blake drains were used, there were no cases of complications or patient complaints of discomfort resulting from drain placement. Moreover, all the cases in which Blake drains were used obtained good wound healing at the drain insertion site over a single period.
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4. Comment
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The application of Blake drains for general thoracic surgery was first reported by Kejriwal and Newmann [2] in 2005. In this report, 19Fr Blake drains were used for 37 cases in which their safety and effectiveness were confirmed. At approximately the same time, Stolz et al. [3] also reported that they used 24Fr Blake drains in the anterior side when placing two thoracic drains and obtained good results, though they cited the low cost-effectiveness as a problem. Subsequently, Ishikura and Kimura [4] reported that they used 19Fr Blake drains and Icard et al. [5] and Saxena et al. [6] reported that they used 24Fr Blake drains, with each report confirming the effectiveness of their respective Blake drains, but these results were obtained from small numbers of cases. We used Blake drains in 420 cases of general thoracic surgery and confirmed that Blake drains can be used for a variety of chest diseases and surgical procedures. We would like to examine whether Blake drains can be considered an acceptable standard drain.
Traditionally, chest tubes have needed to combine the functions of both airs and fluids drainage, but the main concerns regarding Blake drains are twofold: whether blood, milky fluid, and pus can be drained properly and whether they can sufficiently respond to large amounts of air leaks. Niinami et al. [7] compared the suction ability of the 19Fr Blake drain with that of the 28Fr conventional drain and found that while the suction is approximately nine times higher for the conventional drain when used in vitro, there was no significant difference in the amount of drainage over time in an in vivo animal experiment. This is believed to be due to the structure of the Blake drains, which have four open channels that are 30 cm in length from the pointed end, thus enabling a wide-ranging suction ability [5]. While it has been shown that there are no problems in using Blake drains under normal clinical settings, there is still concern regarding its utility in the event of bleeding. The primary role of the drain in the event of bleeding is to enable the acquisition of proper information, and though three of our cases required re-operation for bleeding, each of these cases was treated satisfactorily using 19Fr drains. Clark et al. [8] have reported that when they inserted a 19Fr Blake drain on the right side and a 24Fr conventional drain on the left side in a patient undergoing bilateral bullous resection and talc pleurodesis, life-threatening hypovolemic shock occurred on the right side after the surgery. The cause was attributed to bleeding in the thoracic cavity that could not be drained due to occlusion of the drain that occurred as a result of thrombotic clots and talc particles. However, it is believed that the strongest level of suction in a Blake drain is generated at the groove opening, which is an important portion [4], and because this portion is located at the apical portion of the lung, the drain should be placed in a way that prevents occlusion. In addition, in rare cases in which talc pleurodesis is performed, it is preferable to use a 24Fr Blake drain, which has a stronger suction ability than the 19Fr Blake drain [5]. The effectiveness of 24Fr blake drains as a mediastinal or pericardial drain used after cardiac surgery has been reported in many cases [9, 10], including one report from 2000 by Obey et al. [1], and it is believed that they are effective for draining blood from the thoracic cavity as well. In reports that used 24Fr Blake drains to perform drainage of the thoracic cavity, including a randomized control trial of Blake drains and conventional drains, there is no significant difference between the two groups in their drainage capacity [11–13].
Postoperative chylothorax is a complication that can occur often, but there have thus far been no reports indicating the effectiveness of Blake drains for treating such cases. Our report shows that Blake drains have sufficient functionality for performing drainage. We believe that the discharging of large amounts of turbid liquid is unproblematic. In terms of these concerns, Blake drains can also be used to perform drainage for empyema and pleuritis, but there is still concern that the drain groove will become occluded with fibrin masses and debris, and because the drain has a single lumen, we believed that Blake drains are unsuitable when irrigation of the thoracic cavity is scheduled after surgery.
In cases in which a large amount of pulmonary fistulae is present, there is concern that the use of Blake drains will be unable to provide sufficient air drainage, thus progressing subcutaneous emphysema. In order to sufficiently discharge the air, the site of placement of the drain is important, and we have made adjustments to set the lateral groove opening of the drain at the apical portion of the lung. We believe that air drainage can thus be provided at levels similar to those provided when using a conventional drain. In addition, when pleural adhesions with drugs are required due to persistent air leaks, we believe that it is possible to address these conditions by means of direct injections through the drain as was done in three cases in this study.
Blake drains have a level of functionality that is in no way inferior to that of conventional drains, and they provide the advantages of slenderness and softness to reduce the levels of discomfort experienced by patients during the placement and removal of drains [14]. In addition, it is recommended that each drain should be inserted from a separate part to prevent wound infections such as SSI [15], and it is believed that Blake drains address such concerns adequately while enabling good wound healing as seen in our results. In short, we believe that Blake drains provide enough benefits to be considered a standard drain. In conclusion, we believe that the use of Blake drains for postoperative drainage in the field of general thoracic surgery is an acceptable option. However, there also are with reason a lot of limitations in our single institutional results. We believe that it is worthwhile to proceed with further investigations of larger numbers of cases and plan the randomized comparative studies to determine the optimal types of use and placement methods for specific diseases and surgical procedures.
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References
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Abstract
1. Introduction
