Complications of tube thoracostomy in 603 patients

1. Complications of tube thoracostomy in 603 patients Bülent Koçer, Erkan Yıldırım, Gültekin Gülbahar, Mahmut Kocakel, Erman Öztürk, Kanat Özışık, Koray Dural, Ünal Sakıncı Ankara Numune Teaching and Research Hospital, Division of Thoracic Surgery 2006

2. Summary • Tube Thoracostomy (TT) • Safe • Easy to perform • Cheap • Attention to probable complications and precautions, its easy to decrease the complication rate.

3. Materials and Methods • January 2002- December 2005 (4 years) • 603 patients • Retrospective Analysis • TT performed in patients hospitalized in other clinics were not included in the study.

4. Results • Male :518 (%85,9) • Female :85 (%14,1) • Mean age :32,3 (12-80 years)

5. Results Table 1:TT localizations

6. Table 2: Etiological factors

7. Table 3:TT according to indication

8. Table 4: TT complications

9. Table 5: Treatment policies of TT complications

10. Table 6: Surgical interventions for TT complications

11. Results • Mean drainage time : 3,6 days • Mean hospitalization time : 5,3 days • Mortality of TT : none

12. Discussion • Indications: • Varios reasons of fluid and air collection within pleural cavity (1). • It’s not recommended to use TT in patients with low percentage pneumothorax (Px) • Symptomatic (Regardless of percentage) • Patients in whom positive pressure ventilation will be used TT is indicated (2,3). 1) Yıldızeli B, Yüksel M. Plevra Hastalıklarında Cerrahi Teknikler. Toraks Derg 2002;3: 30–44 2) Light RW. Hemotorax. In Light RW. Pleural Disease. William&Wilkins, Maryland. 1995;278–283 3) Bowling WM, Wilson RF, Kelen GD, Buchman TG. Thoracic Trauma. In: Emergency Medicine. A Comprehensive Study Guide, Fifth Edition, Tintinalli JE, Kelen GD, Stapczynski JS (eds), McGraw-Hill Professional 2000; 1675–1699

13. Discussion • Malposition of the tube; • Re-insertion of the tube from a different site (4,5). • Position of the tube have no critical role for drainage (6). • In our clinic, we do not prefer to change the tube if there is no drainage problem 4) Jones JW, Kitahama A, WebB WR, McSwain N. Emergency thoracoscopy: a logical approach to chest trauma management. J Trauma. 1981 Apr;21(4):280–4. 5) Smith RS,Fry WR Tsoi EK, Morabito DJ, Koehler RH, Reinganum SJ, OrganCH Jr. Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury. Am J Surg. 1993;166(6):690–3 6) Curtin JJ, Goodman LR, Quebbeman EJ, Haasler GB. Thoracostomy tubes after acute chest injury: Relationship between location in a pleural fissure and function. Am J Roentgenol 1994;163:1339–42

14. Discussion • Malposition ineffective drainage change in localization of TT 12 patients • 4 patients underwent surgical intervention (33.3%) • Drainage type and amount must be followed carefully even with excellent drainage • In any suspicion, tube must be changed.

15. Discussion • Ineffective drainage Incomplete expansion of the lung Empyema (7). • Another cause of empyema is TT procedure itself. • Some authors recommend prophylactic antibiotherapy (8,9). 7) Eddy AC, Luna GK, Copass M.Empyema thoracis in patients undergoing emergent closed tube thoracostomy for thoracic trauma. Am J Surg 1989;157: 494–7 8) Nicols RL, Smith JW, Muzik AC, Love EJ, McSwain NE, Timberlake G Flint LM. Preventive antibiotic usage in traumatic thoracic injuries requiring closed tube thoracostomy. Chest. 1994;106(5):1493-8. 9) LoCurto JJ Jr, Tischler CD, Swan KG Rocko JM, Blackwood JM, Griffin CC, Lazaro EJ, Reiner DS. Tube thoracostomy and trauma: antibiotics or not? J Trauma 1986; 26: 1067-72

16. Discussion • TT No bacterial colonization at 6th day (10). • TT (80 patients) No emprical antiobiotic use No empyema(11). • In our clinic; • For TT Cefazolin Na For 2 days • We have not observed empyema . 10) Hornick P, John LCH, Wallis J et al. Contamination of underwater seal drainage systems in thoracic surgery. Ann R Coll Surg Engl 1992:74;26-8 11) Davis JW, Mackersie RC, Hoyt DB, et al: Randomized study of algorihms for discontinuing tube thoracostomy drainage. J Am col Surg 1994:179;553-7

17. Discussion • TT Lung laceration • Tension Px (12). • Prolonged air leak after TT Thoracotomy Laceration due to TT 12) McConaghy PM, Kennedy N. Tension pneumothorax due to intrapulmonary placement of intercostal chest drain. Anaesth Intensive Care. 1995;23(4):496–8.

18. Discussion • TT Abdominal organ injury (13). • After TT; • Right hemidiaphragm elevation • Liver laceration • At left, hemothorax+diaphragmatic rupture • Gastric perforation • Splenic laceration • These petients were operated by general surgery clinics. 13) Symbas PN. Chest dranaige tubes. Surg Clin North Am 1989;69: 41–6.

19. Discussion • Re-expansion edema TT sudden expansion of the collapsed lung may be lethal • Edema; • Mostly limited • Fatal in 20% of the patients (14). • No re-expansion edema was observed. • Intermittant clamping may be helpful. 14) Mahfood S, Hix WR, Aaron BL Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg 1988;45: 340–5

20. Discussion • TT Hemorrhage While insertion just beneath the rib • Mostly in elderly because of arteriosclerosis (1). • Other possible causes of hemorrhage: • Cardiac causes ( R atrium, R and L ventricle) • Great vessels ( vena cava, main pulmonary artery, aort) • Suprahepatic vein • Rare • Mostly at TT procedures where, trocar system is used (1). • We did not experienced serious hemorrhage in our series. 1) Yıldızeli B, Yüksel M. Plevra Hastalıklarında Cerrahi Teknikler. Toraks Derg 2002;3: 30–44

21. Discussion • TT Cardiac compression Arrythmia • Change the position of the tube (15). 15) Kaya ŞÖ. Toraks travmalarında girişimsel işlemler. In: Travma. First ed, Doğan R, Taştepe İ, Liman ŞT (eds) MN Medikal&Nobel. 2006;30: 457–465

22. Discussion • TT Horner’s Syndrome (16). • Transient • Nerve compression at cupula. • Tube must be withdrawn to avoid compression (1). • We did not experienced Horner’s Syndrome in our patients. 1) Yıldızeli B, Yüksel M. Plevra Hastalıklarında Cerrahi Teknikler. Toraks Derg 2002;3: 30–44 16) Kaya ŞÖ, Çakan A, Yuncu G. Horner’s syndrome, anusual complication. Minevra Pneumol 2001;40: 49–51

23. Discussion • Empyema TT insertion site problems • Infection at the tube tract • Tissue loss around insertion site and persistant Px • 3 patients (0.5%) • These tubes were removed and TT performed from a different point.

24. Discussion • Timing of tube removal is still controversial. • In a study; • TT 6 hours 25% recurrence • TT 48 hours no recurrence (17). • In another study; • 24 hours without air leak • Drainage <2 ml/kg/day was found to be safe for tube removal (18). 17) Sharma TN, Agnihotri SP, Jain NK, Madan A, Deopura G. Intercostal tube thoracostomy in pneumothorax-factors influencing re-expansion of lung. Indian J Chest Dis Allied Sci 1988;30: 32–5 18) Davis JW, Mackersie RC, Hoyt DB, Garcia C. Randomized study of algorithms for discontinuing tube thoracostomy drainage. J Am Col Surg 1994:179;553–7

25. Discussion • In our practice; • We prefer to remove the tube: • 24 hours after cessation of air leak • Daily drainage below 50-100 cc according to its character • In this study; • Recurrent Px in 3 patients (0.5%) • In 1 patient low percentage Px follow-up • For 2 patients TT

26. Discussion • Accidental injury to the tube while removing the fixation suture. • Tube removed clamped • Low percentage Px radiologically Follow-up • Fixation suture; • Must be removed by appropriate scalpel • Scalpel direction must be towards the opposite side away from the tube

27. Discussion • Persistant Px Clamp the tube Control x-ray after 12-24 hours (19) . • Any problem at insertion site? • If yes Do not clamp the tube. • Remove it with aspiration • Recurrence Insert it from a different point. 19) Martino K, Merrit S, Boyakye K et al. Prospective randomized trial of thoracostomy removal algorithms. J Traum 1999; 46: 369–71

28. Conclusion • TT is a life saving and safe procedure with low morbidity • Universal probable complications must always be kept in mind during procedure and with high grade precautions, its easy to decrease morbidity and mortality rate.