Minimal pulmonary resection and minor chest procedures: is pleural drainage systematically necessary?

To the Editor:

   Chest tube placement is considered an obligatory step in thoracic surgery (4,5), and post thoracotomy pleural drainage is not subject to criticism (3). However, in some situations, chest tube drainage con be avoided without risk, even when we perform minor lung resections. The development of atraumatic sutures and mechanical staplers has made possible an air tight section of lung tissue, allowing pulmonary resections with effective hemostasis and aerostasis. If you control bleeding and air leaks and have an effective expansion of the reminiscent lung, pleural drains are not necessary.
Larger resections may demand the use of strips of cellulose or pericardium to buttress the suture. Resections performed out from the free border of the lung should be carefully closed to avoid air leakage. Special care is necessary for larger resectrions that require a V or U shape wedge resection. Intersections of the staples lines should be complete and when it is not possible they should be completed by manual buttressed sutures. Careful lung insufflation at the end of the procedure eliminates residual pleural fluids and check's air leaks. Surgeon and anesthesiologist communication is impoartant to achieve complete lung expansion. Following these steps leads to a small incidence of pleural space problems and makes pleural drainage unnecessary.

We must point out that the decision to avoid pleural drainage should be taken at the end of the operation when security conditions habe been achieved. The absence of chest tubes in the post operative period offers comfort and less pain for the patient, less hospital stay and even less expense. Nursing care is simplified and patients activities are not hampered (2).

So far, this approach was taken in 86 patients who underwent diverse intrathoracic procedures (Table 1), and 64 underwent lung resection. Lung biopsey, nodule or wedge resections were performed through minimal incisions.



TABLE 1 - List of 86 intrathoracic operations in which post operative chest tube drainage was avoided

	No. of operations
Open pulmonary biopsy*	32
Pulmonary biopsy by Videothoracoscopy*	8
Wedge resection*	12
Nodule resetion*	12
Video-assisted resection of mediastinal tumor	7
Video-assisted thoracic sympathectomy	6
Chest wall resection (3 ribs)	9
TOTAL	86

*Patients that had any kind of pulmonary manipulation and ressection

Efficient hemostasis and aerostasis have been achieved with manual sutures of polypropylene 5-0 or 6-0 (43 patients) or using linear cutting staplers (11 patients). Nodule resection using the conventional precision electrocoagulation technique was performed in 12 patients (1).
All patients underwent a post operative chest film to control pneumothorax or pleural effusion. Four patients presented minor pneumothoraces. There was a reduction in two and disappearance of pleural air in the other two, after 24 h. Mild subcutaneous emphysema was found in for patients. We had no problem related to the absence of chest tube drainage. The small number of patients with pneumothorax (none had to be evacuated) in our experience, reflect the efficient aerostatic sutures and lung expansion. In thes serie, 42 patients were discharged before 24 h the other 44 before 48 h and pain was easily controlled by oral analgesics.

Avoid drainage in some thoracic operations is a safe procedure and allows simplification and increased postoperative comfort. We are so used to the idea of draining any violation of the pleural space that we do not assume the actual necessity of the procedure.

REFERENCES
(1) Cooper JD, Perelman M Todd TRJ, Ginsberg RJ, Pattersom GA, Pearson FG. Precision cautery excision of pulmonary lesion. Ann Thorac Surg 1986;41:51-3
(2)Heerden JA, Lynn HB. An evaluation of tube thoracostomy in pediatric surgery. Virginia Medical Monthly 1972;99:139-41.
(3)Miller KS, Sahn SA. Chst tubes - Indications, techniques management and complications. Chest 1987;91:258-60.
(4)Symbas PN. Chest drainage tubes. Surg Clin North Am 1989;69:41-6.
(5)Walkins E. Principles of post operative management in thoracic surgery. Surg Clin North Am 1961;41:603-9.

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Angelo Fernandez. Rua da Consolação, 3726 apto-132,01416-000 São Paulo, Brazil.

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