Thoracic: Lung
Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection

Read at the 103rd Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, California, May 6-9, 2023.
https://doi.org/10.1016/j.jtcvs.2023.05.017Get rights and content

Abstract

Objectives

The need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients.

Methods

Patients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses.

Results

A total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion.

Conclusions

Reserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.

Section snippets

Study Design

A retrospective review of a prospectively collected database was performed on patients who underwent elective anatomic or nonanatomic lung resection from January 2007 to April 2013. During this time, our institution's practice was transitioning from ordering routine CXR upon CT removal (typically within four hours) and at the first outpatient postoperative follow-up (typically, 2 weeks postoperatively) to ordering CXR as indicated for symptoms and clinical signs of concern (new/increasing

Primary Outcome

A total of 322 patients met inclusion criteria (Figure 1). Of these, 93 patients received a routine post-pull CXR and 229 did not (Table 1). Post-pull CXR ordering practice by year ranged from 23% to 35%, and there was no clear inflection point due to varying surgeon practice during this time (Figure 2, A). Baseline patient characteristics did not differ between groups except significantly more Black/African American patients received routine CXR (22.6% vs 11.4%, P = .028). There was also no

Discussion

The necessity of ordering CXR after CT removal following pulmonary resection has been questioned for a long time.3,9,11 In 2008, we started the transition from ordering routine CXR the day of CT removal and at the first outpatient clinic visit to only ordering imaging on an as-needed basis. Our current routine is to order an immediate postoperative CXR and one 4 hours after the CT is placed on water seal and no further imaging unless a patient develops signs or symptoms that may indicate a

Conclusions

After elective lung resection, routine CXR obtained immediately after CT removal and at the first postoperative follow-up rarely, if ever, results in meaningful changes in management. This practice of routine CXR in asymptomatic patients is not only ineffective but also associated with significance cost and potential harm from unwarranted interventions. Using a selective approach to obtaining CXR based on concerning symptoms or signs is safe and has the potential to results in significant

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This study was approved by the University of Cincinnati Medical Center Institutional Review Board; IRB#: 2013 to 5266, date of approval: August 29, 2013.

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