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Interact CardioVasc Thorac Surg 2009;9:645-648. doi:10.1510/icvts.2009.212522 © 2009 European Association of Cardio-Thoracic Surgery
Comparison of methods for placing and managing a silastic drain after pulmonary resection
a Department of Thoracic Surgery, Aichi Cancer Center Hospital, Nagoya, Japan Received 22 May 2009; received in revised form 10 July 2009; accepted 14 July 2009
*Corresponding author. 1-1, Kanokoden, Chikusa-Ku, Nagoya 464-0021, Japan. Tel.: +81-52-762-6111; fax: +81-52-764-2967.
We have been using a silastic drain [Blake® drain (BD)] after pulmonary resection by different placement methods and reviewed the daily amount of drainage in each patient. A 19-Fr BD was placed for each of 110 patients. First, a drain was inserted from the anterior chest wall and the tip reached the dorsal part of the diaphragm [anterior-to-posterior (AP)]. For the others [posterior-to-anterior (PA); n=37], we inserted a drain from the lower intercostal space, turned it around the apex and placed its tip in the lower front. Patients in the AP group included those placed under a water seal (AP-WS; n=43) or suction (AP-SC; n=30). The reference group consisted of 68 patients with a 32-Fr plastic drain during the same period [conventional drains (CD)]. The amount of drainage on the day of surgery in the PA group was significantly higher than that in the AP-WS group (P<0.0001) and similar to that in the CD group (P=0.54). The mean amount of drainage on postoperative day 1 and total amounts accumulating during drain placement showed no significant differences between the four groups. A BD placed using a PA approach with suction might be efficient for drainage.
Key Words: Blake; Drainage; Lung cancer surgery
The main purposes for inserting a chest tube after pulmonary resection are to drain pleural effusion and to ensure adequate respiratory function by maintaining a negative pressure in the thoracic cavity and thereby promoting distension of the remaining lung. The tube also serves as an ‘information drain’ for detecting any abnormalities in the thoracic cavity. Rigid plastic tubes with a large diameter (24–32 Fr) are commonly used for the tube after pulmonary resection in many institutions; however, these hard and large tubes may cause discomfort and pain in patients and thus can delay postoperative recovery. The Blake® silastic drain (BD, Ethicon, Inc, Somerville, NJ, USA) used in the present study has a soft and folding-resistant tubular structure with a 30-cm long groove, which theoretically prevents blockage caused by blood. Whereas this drain is mainly used for subcutaneous drainage after breast or thyroid surgery and mediastinal drainage after cardiovascular surgery [1–3], several studies have used it as a chest tube after pulmonary resection and suggested its functional benefit, as it causes little pain at the site of drain insertion and has sufficient drainage performance [4–8]. However, no study on the most effective method for placing a BD has been conducted. In our institution, we have been using a 19-Fr BD for post-pulmonary-resection drainage since December 2005 and have tried various methods for placing the drain as well as methods of postoperative management. In the present study, we retrospectively evaluated the various methods, focusing on such parameters as the daily amount of drainage.
2.1. Patients Approval for this study was obtained and the need for individual patient consent was waived by the institutional review board. Each patient was informed that his or her clinical data might be used for various studies, and consent was obtained on this basis. We studied 110 patients in whom a 19-Fr BD was used for postoperative chest drainage since December 2005. The patients comprised 57 men and 53 women, with a median age of 64 years. Surgical procedures included lobectomy in 95 patients, segmentectomy in 7, and partial resection in 8. All of the surgical procedures in this series were open. The patients were examined for the status of drainage, such as postoperative daily amounts, and total amount and the duration of drain placement, compared with a reference group consisting of 68 patients in whom a conventional 32-Fr rigid drain during the same period [conventional drains (CD) group]. 2.2. Methods for placing a drain From December 2005 to March 2007, according to the manufacturer's instruction, we inserted a drain from the anterior chest wall and advanced the drain around the lung apex until the tip of the tube reached the dorsal inferior part of the diaphragm (anterior-to-posterior placement; AP group; n=73; Fig. 1). The drain was then connected to a 3-chamber unit that can create negative pressure in the thoracic cavity. Patients in the AP group consisted of two groups; those whom placed under water seal without suction (AP-WS group; n=43) and those placed under water seal with suction at –10 cm H2O (AP-SC group; n=30) immediately after surgery.
We have been using a different drain placement method since April 2007. The drain was inserted from the lower part of the intercostal space where the thoracotomy was made, advanced upwards in the posterior part of the thoracic cavity, turned around the apex and placed with its tip located in the lower front of the lung (posterior-to-anterior placement; PA group; n=37; Fig. 2). All patients in the PA group were placed under water seal with suction at –10 cm H2O immediately after surgery. Drains were removed when it was confirmed that there was no air leakage, that the drained fluid was not bloody and that daily amount of fluid was <200 ml. All CD were inserted from the lower anterior axillary line of thoracotomy to the apical direction under water seal without suction. The assignment of individual patients to BD or CD intervention and the BD's initial suction was made at the discretion of the operating surgeon. In all groups, one BD or one CD was placed for each patient.
2.3. Statistical analyses To evaluate the efficiency of each drainage protocol, we calculated the percentages of daily amounts based on the total drainage. The Kruskal–Wallis test was carried out to compare the distribution of age, amount of drainage and duration of hospital stay between groups. The  2-test for independence was used to compare other clinicopathological parameters. P<0.05 was regarded as statistically significant and calculations were performed using StatView version 5.0 (SAS Institute Inc, Cary, NC, USA).
There was no between-group bias in age, gender, disease or surgical procedure, as shown in Table 1. The mean amount of fluid on the day of surgery was 84 ml (range 0–450 ml) in the AP-WS group, 157 ml (14–490 ml) in the AP-SC group, 181 ml (20–390 ml) in the PA group and 196 ml (6–680 ml) in the CD group. The amount in the PA group was significantly higher than that in the AP-WS group (P<0.0001) and similar to that in the CD group (P=0.54, Fig. 3a). It is noteworthy that in the AP-WS group, 10 patients (23%) had <10 ml of drainage and 5 patients (12%) had no drainage on the day of surgery. The mean amounts of drainage on postoperative day 1 were 223 ml, 292 ml, 221 ml and 264 ml in the AP-WS, AP-SC, PA and CD groups, respectively, with no significant differences between groups (Fig. 3b). There also were no significant differences in the total amount of drainage during the drain placement period between groups (Fig. 3c).
The percentage drainage on the day of surgery was 16%, 19%, 24% and 28% in the AP-WS, AP-SC, PA and CD groups, respectively, revealing that the most efficient drainage with BD was obtained in the PA group (Fig. 4).
The mean duration of drain placement was 3.2 d, 3.3 d, 3.9 d and 3.0 d in the AP-WS, AP-SC, PA and CD groups, respectively, showing a slightly longer duration of drain placement in the PA group than in the other groups (Fig. 5).
No patients in the PA group developed severe pleural effusions that required replacement of a drain or repeat operation, or were troubled by aggravation of subcutaneous emphysema.
We have been using a 19-Fr BD as a chest tube after pulmonary resection since December 2005. We initially placed a drain AP method, followed by immediate management with a water seal system, as in the case of conventional rigid drains. However, we experienced several patients who had only a small amount of drainage of pleural effusion after surgery until the following morning (i.e. <10 ml/day in 22% of patients) and concluded that the drain was not functioning sufficiently as an information drain. We then began employing continuous suction at –10 cm H2O, similar to a previous report [4]. This provided a slight improvement, but the results were still not satisfactory. We thus modified the drain placement to PA method, followed by immediate management with continuous suction. The initial insufficient drainage in the AP group, for whom a drain was inserted from the anterior chest wall, may be explained by the difficulty in draining fluid while patients were required to stay in a supine position. In this position, fluid flows upwards against gravity by the anteroposterior length of the thoracic cavity and then flows down into the unit. Failure in this upward flow might have resulted in the small amount of drainage. Moreover, the third method used in the PA group exhibited a similar level of drainage performance to that of the conventional method using a 32-Fr rigid drain and no patient experienced drain-associated complications such as bleeding, blockage or infections with this method. These results demonstrate that the silastic drain functions effectively as a chest tube after pulmonary resection, if appropriately placed and managed. Although Clark et al. reported a case of a massive hemothorax due to obstruction of the BD following pulmonary resection [9], we did not experience similar troubles caused by relatively small diameter of the BD.
The duration of drainage was 3.9 days in the PA group, which was very close to that in a previous report [7] but was longer than that with our conventional 32-Fr drain by The results of the present study suggested the tolerability of soft and thin drains as a chest tube after regular pulmonary resection. Although it would be ideal to conduct a randomized controlled study to compare standard rigid plastic drains and silastic drains, a large number of patients would be required to draw some conclusions from such a study because of the relatively low incidence of tube-related problems. Moreover, evaluation of drain-related pain is complicated by pain from the thoracotomy wound and individual differences in sensitivity to pain, making it more difficult to conduct this kind of study. In our opinion, we believe that drainage using a silastic drain improves postoperative comfort for patients and reduces pain during removal of a drain. Indeed postoperative pain can be, and should be, measured, and probably silastic drains will be more appropriate and efficient in the setting of video-assisted thoracoscopic surgery. Furthermore, although this is only our opinion, the appearance of healed wounds in patients receiving the BD was more favorable than that in patients receiving the CD. We have had an impression that a soft and thin drain is not functionally inferior to the conventional rigid drain concerning the fluid drainage. We have also speculated that a silastic drain (BD) placed using a PA approach, where a drain is inserted from the posterior part of the thoracic cavity and placed with its tip located in the anterior part with suction, might be efficient for fluid drainage.
We thank Dr Keitaro Matsuo, Division of Epidemiology and Prevention, Aichi Cancer Center Research Institute, for his advice on statistical analyses.
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Abstract
1. Introduction
1 day on average. We speculate on the reason for this as follows. The first possibility is that the 19-Fr drain was too thin, considering that the amount of drainage per unit time is dependent on the cross-section area of the drain lumen, and thus prolonged the duration of drain placement. Another possibility is that effective and continuous drainage with the BD even after several days resulted in the prolongation of the duration of drain placement. This is because the drain is theoretically resistant to blockage caused by blood clots because of its folding-resistant tubing structure and a 30-cm long groove, and because continuous suction from the entire length of the groove provides a high efficiency of drainage via a large tissue contact surface area.