Comment on digital chest drainage is better than traditional chest drainage following pulmonary surgery: a meta-analysis

Comment on digital chest drainage is better than traditional chest drainage following pulmonary... Lung resection , Postoperative care , Pleural drainage , Electronic pleural drainage In this issue of the European Journal of Cardio-Thoracic Surgery, Zhou et al. [1], in a well-conducted meta-analysis, concluded that using digital chest drainage systems might be necessary to reduce air leak and hospital stay after pulmonary surgery. As systematic reviews on randomized controlled trials are placed at the top of the hierarchy of evidence [2], the question is, should the use of digital pleural drainage systems be recommended as a routine after lung resection? The answer is no; or, at least, the evidence is inconclusive. To the best of our knowledge, when compared with the systematic review published in 2014 by Afoke et al. [3], the current meta-analysis still does not give an answer to the question. Although the authors have conducted a credible review and meta-analysis, we would like to suggest a few points that should be considered by the readers of the article by Zhou et al. [1]. The first one is related to the outcomes. The authors have selected 3 main outcomes to be analysed: time to chest tube withdrawal, duration of air leak and hospital stay. No conclusions can be expected regarding the first one due to the heterogenous amount of pleural fluid ranging 200–450 ml in 24 h to pull out chest tubes as stated in the articles included in the meta-analysis. The other 2 outcomes could be considered as the same because air leak is the main variable influencing hospital stay after lung resection [4]; indeed, in pulmonary surgery, hospital stay is a surrogate to the duration of an air leak. In a previous article [5], we have concluded that the use of digital drainage systems improved the observers’ agreement to withdraw chest tubes. Better interobserver agreement could be linked to shorter time with chest tubes and, consequently, shorter hospital stay. In addition, digital monitoring of air leaks could be useful for predicting prolonged air leak, allowing earlier discharge with portable drainage units [6], and, hence, electronic systems could be linked to shorter hospital stay. However, as the occurrence of prolonged air leak can also be accurately performed using conventional drainage systems [7], the recommendation to use more expensive ones is arguable. The second point is how much more the length of hospital stay is reduced using digital chambers? If we carefully analyse data offered by the authors, in only 3 of 10 trials, the length of hospital stay was decreased by 1 day or more [8–10], and one of those trials [8] should have been excluded from the analysis since in most of the cases in the series, surgery was not indicated. Thus, the differences in length of staging between patients with digital and analogical devices (in operated patients) ranged 0–1 with a median of 0.7 days (<17 h); in other words, patients could be discharged in the evening instead of staying overnight. According to the GRADE approach [11], using digital devices for pleural drainage cannot be considered a strong recommendation. We doubt that most clinicians, patients and policy makers would select a policy of digital control of chest tubes after knowing that the procedure does not improve primary outcomes (postoperative mortality, morbidity and quality of life) and that the only advantage is that non-complicated patients will be probably discharged home 17 h earlier. REFERENCES 1 Zhou J , Lyu M , Chen N , Wang Z , Hai Y , Hao J et al. Digital chest drainage is better than traditional chest drainage following pulmonary surgery: a meta-analysis . Eur J Cardiothorac Surg 2018 :doi:10.1093/ejcts/ezy141. 2 Oxford Centre for Evidence-based Medicine—Levels of Evidence (March 2009) . https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ (18 March 2018, date last accessed). 3 Afoke J , Tan C , Hunt I , Zakkar M. Might digital drains speed up the time to thoracic drain removal? Interact CardioVasc Thorac Surg 2014 ; 19 : 135 – 8 . Google Scholar CrossRef Search ADS PubMed 4 Bardell T , Petsikas D. What keeps postpulmonary resection patients in hospital? Can Respir J 2003 ; 10 : 86 – 9 . Google Scholar CrossRef Search ADS PubMed 5 Varela G , Jiménez M , Novoa N , Aranda JL. Postoperative chest tube management: measuring air leak using an electronic device decreases variability in the clinical practice . Eur J Cardiothorac Surg 2009 ; 35 : 28 – 31 . Google Scholar CrossRef Search ADS PubMed 6 Takamochi K , Imashimizu K , Fukui M , Maeyashiki T , Suzuki M , Ueda T et al. Utility of objective chest tube management after pulmonary resection using a digital drainage system . Ann Thorac Surg 2017 ; 104 : 275 – 83 . Google Scholar CrossRef Search ADS PubMed 7 Rodríguez M , Jiménez MF , Gómez-Hernández MT , Novoa NM , Aranda JL , Varela G. Usefulness of conventional pleural drainage systems to predict the occurrence of prolonged air leak after anatomical pulmonary resection . Eur J Cardiothorac Surg 2015 ; 48 : 612 – 15 . Google Scholar CrossRef Search ADS PubMed 8 Jablonski S , Brocki M , Wawrzycki M , Smigielski JA , Kozakiewicz M. Efficacy assessment of the drainage with permanent airflow measurement in the treatment of pneumothorax with air leak . Thorac Cardiovasc Surg 2014 ; 62 : 509 – 15 . Google Scholar PubMed 9 Pompili C , Detterbeck F , Papagiannopoulos K , Sihoe A , Vachlas K , Maxfield MW et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems . Ann Thorac Surg 2014 ; 98 : 490 – 6 . Google Scholar CrossRef Search ADS PubMed 10 Lijkendijk M , Licht PB , Neckelmann K. Electronic versus traditional chest tube drainage following lobectomy: a randomized trial . Eur J Cardiothorac Surg 2015 ; 48 : 893 – 8 . Google Scholar CrossRef Search ADS PubMed 11 Andrews J , Guyatt G , Oxman AD , Alderson P , Dahm P , Falck-Ytter Y et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations . J Clin Epidemiol 2013 ; 66 : 719 – 25 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Comment on digital chest drainage is better than traditional chest drainage following pulmonary surgery: a meta-analysis

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Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1010-7940
eISSN
1873-734X
D.O.I.
10.1093/ejcts/ezy162
Publisher site
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Abstract

Lung resection , Postoperative care , Pleural drainage , Electronic pleural drainage In this issue of the European Journal of Cardio-Thoracic Surgery, Zhou et al. [1], in a well-conducted meta-analysis, concluded that using digital chest drainage systems might be necessary to reduce air leak and hospital stay after pulmonary surgery. As systematic reviews on randomized controlled trials are placed at the top of the hierarchy of evidence [2], the question is, should the use of digital pleural drainage systems be recommended as a routine after lung resection? The answer is no; or, at least, the evidence is inconclusive. To the best of our knowledge, when compared with the systematic review published in 2014 by Afoke et al. [3], the current meta-analysis still does not give an answer to the question. Although the authors have conducted a credible review and meta-analysis, we would like to suggest a few points that should be considered by the readers of the article by Zhou et al. [1]. The first one is related to the outcomes. The authors have selected 3 main outcomes to be analysed: time to chest tube withdrawal, duration of air leak and hospital stay. No conclusions can be expected regarding the first one due to the heterogenous amount of pleural fluid ranging 200–450 ml in 24 h to pull out chest tubes as stated in the articles included in the meta-analysis. The other 2 outcomes could be considered as the same because air leak is the main variable influencing hospital stay after lung resection [4]; indeed, in pulmonary surgery, hospital stay is a surrogate to the duration of an air leak. In a previous article [5], we have concluded that the use of digital drainage systems improved the observers’ agreement to withdraw chest tubes. Better interobserver agreement could be linked to shorter time with chest tubes and, consequently, shorter hospital stay. In addition, digital monitoring of air leaks could be useful for predicting prolonged air leak, allowing earlier discharge with portable drainage units [6], and, hence, electronic systems could be linked to shorter hospital stay. However, as the occurrence of prolonged air leak can also be accurately performed using conventional drainage systems [7], the recommendation to use more expensive ones is arguable. The second point is how much more the length of hospital stay is reduced using digital chambers? If we carefully analyse data offered by the authors, in only 3 of 10 trials, the length of hospital stay was decreased by 1 day or more [8–10], and one of those trials [8] should have been excluded from the analysis since in most of the cases in the series, surgery was not indicated. Thus, the differences in length of staging between patients with digital and analogical devices (in operated patients) ranged 0–1 with a median of 0.7 days (<17 h); in other words, patients could be discharged in the evening instead of staying overnight. According to the GRADE approach [11], using digital devices for pleural drainage cannot be considered a strong recommendation. We doubt that most clinicians, patients and policy makers would select a policy of digital control of chest tubes after knowing that the procedure does not improve primary outcomes (postoperative mortality, morbidity and quality of life) and that the only advantage is that non-complicated patients will be probably discharged home 17 h earlier. REFERENCES 1 Zhou J , Lyu M , Chen N , Wang Z , Hai Y , Hao J et al. Digital chest drainage is better than traditional chest drainage following pulmonary surgery: a meta-analysis . Eur J Cardiothorac Surg 2018 :doi:10.1093/ejcts/ezy141. 2 Oxford Centre for Evidence-based Medicine—Levels of Evidence (March 2009) . https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ (18 March 2018, date last accessed). 3 Afoke J , Tan C , Hunt I , Zakkar M. Might digital drains speed up the time to thoracic drain removal? Interact CardioVasc Thorac Surg 2014 ; 19 : 135 – 8 . Google Scholar CrossRef Search ADS PubMed 4 Bardell T , Petsikas D. What keeps postpulmonary resection patients in hospital? Can Respir J 2003 ; 10 : 86 – 9 . Google Scholar CrossRef Search ADS PubMed 5 Varela G , Jiménez M , Novoa N , Aranda JL. Postoperative chest tube management: measuring air leak using an electronic device decreases variability in the clinical practice . Eur J Cardiothorac Surg 2009 ; 35 : 28 – 31 . Google Scholar CrossRef Search ADS PubMed 6 Takamochi K , Imashimizu K , Fukui M , Maeyashiki T , Suzuki M , Ueda T et al. Utility of objective chest tube management after pulmonary resection using a digital drainage system . Ann Thorac Surg 2017 ; 104 : 275 – 83 . Google Scholar CrossRef Search ADS PubMed 7 Rodríguez M , Jiménez MF , Gómez-Hernández MT , Novoa NM , Aranda JL , Varela G. Usefulness of conventional pleural drainage systems to predict the occurrence of prolonged air leak after anatomical pulmonary resection . Eur J Cardiothorac Surg 2015 ; 48 : 612 – 15 . Google Scholar CrossRef Search ADS PubMed 8 Jablonski S , Brocki M , Wawrzycki M , Smigielski JA , Kozakiewicz M. Efficacy assessment of the drainage with permanent airflow measurement in the treatment of pneumothorax with air leak . Thorac Cardiovasc Surg 2014 ; 62 : 509 – 15 . Google Scholar PubMed 9 Pompili C , Detterbeck F , Papagiannopoulos K , Sihoe A , Vachlas K , Maxfield MW et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems . Ann Thorac Surg 2014 ; 98 : 490 – 6 . Google Scholar CrossRef Search ADS PubMed 10 Lijkendijk M , Licht PB , Neckelmann K. Electronic versus traditional chest tube drainage following lobectomy: a randomized trial . Eur J Cardiothorac Surg 2015 ; 48 : 893 – 8 . Google Scholar CrossRef Search ADS PubMed 11 Andrews J , Guyatt G , Oxman AD , Alderson P , Dahm P , Falck-Ytter Y et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations . J Clin Epidemiol 2013 ; 66 : 719 – 25 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 13, 2018

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