Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Intrapleural streptokinase for empyema and complicated parapneumonic effusions. Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study. A randomised prospective trial of surgical against medical tetracycline pleurodesis in the management of malignant pleural effusions secondary to breast cancer. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Early removing gastrointestinal decompression and early oral feeding improve patients' rehabilitation after colorectostomy. Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. French Associations for Surgical Research. Prospective clinical comparison of two methods for mechanical ventilation of neonates: rapid rate and short inspiratory time versus slow rate and long inspiratory time. A prospective randomised study of drains in infra-peritoneal rectal anastomoses.
Although there is no agreement on the optimal treatment of patients presenting with a first episode of primary spontaneous pneumothorax, the majority of physicians prefer chest tube drainage for air evacuation. Manual aspiration of air has been proposed by some, but lack of sound comparative data and safety data has limited its use. In this first randomized, prospective, multicenter pilot study, 60 patients with a first episode of primary spontaneous pneumothorax were randomly allocated to manual aspiration (n = 27) or chest tube drainage (n = 33). Immediate success was obtained in 16 out of 27 (59.3%) in the manual aspiration group, and in 21 out of 33 (63.6%) in the chest tube drainage group (p = 0.9). One-week success rates were 25 out of 27 (93%) in the intention-to-treat manual aspiration group and 28 out of 33 (85%) in the chest tube drainage group (p = 0.4). Fourteen of 27 manual aspiration patients (52%) were hospitalized, versus 100% of the chest tube drainage patients (p < 0.0001). Recurrence rates with at least 1-year follow-up were 7 out of 26 (26%) in the manual aspiration group, and 9 out of 33 (27.3%) in the chest tube drainage group (p = 0.9). There were no complications associated with manual aspiration. Although statistical power is insufficient to formally confirm therapeutic equality, this pilot study suggests that in first episodes of primary spontaneous pneumothorax, manual aspiration seems equally effective as chest tube drainage and is safe, well tolerated, and feasible as an outpatient procedure in the majority of patients. We conducted a single-center, randomized, placebo-controlled trial to determine whether streptokinase instillations adjunctive to chest tube drainage reduce the need for surgery and improve outcome in patients with pleural empyema. Fifty-three patients (frank pus aspirated, 81%; microbiological agent cultured, 62%; mean effusion pH, 6.6 +/- 0.4) received antibiotic treatment, chest tube drainage, and once-daily pleural rinses with either normal saline or normal saline with streptokinase (250,000 IU). Nine patients were excluded for various reasons before pleural rinses were started. Streptokinase (n = 22) was instilled over 4.5 +/- 2 days and saline (n = 22) was instilled over 3 +/- 1.3 days. One patient in each group died during treatment. Clinical treatment success and need for referral to surgery were the main outcome measures. No difference was observed after 3 days. After 7 days, streptokinase-treated patients had a higher clinical success rate (82 vs. 48%, p = 0.01) and fewer referrals for surgery (45 vs. 9%, p = 0.02). No significant radiologic or functional differences were observed between groups during follow-up over 6 months. We conclude that intrapleural streptokinase adjunctive to chest tube drainage reduces the need for surgery and improves the clinical treatment success in patients with pleural empyema. Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. However, controlled studies of the possible role of the activity of urokinase (UK) through the volume effect are lacking. We therefore investigated the hypothesis that UK is effective through the lysis of pleural adhesions and not through the volume effect. Thirty-one consecutive patients with multiloculated pleural effusions were randomly assigned to receive either intrapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a chest tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasonography (US) and/or computed tomography (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mean volume drained during the 3-d treatment period was significantly greater in the UK group (970 +/- 75 ml versus 280 +/- 55 ml, p < 0.001). Pleural fluid drainage was complete in 13 (86.5%) patients in the UK group (two patients were treated through video-assisted thoracoscopy) but in only four (25%) in the control group. Twelve patients in the control group were subsequently treated with UK and six of them had complete drainage; the remaining six patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculated pleural effusions through the lysis of pleural adhesions and not through the volume effect. Malignant pleural effusion is a frequent complication of metastatic breast cancer leading to a significant degree of morbidity. Drainage of the effusion by thoracocentesis and pleurodesis with tetracycline as the sclerosing agent is an established means of symptomatic relief in these patients. To determine whether the efficacy of tetracycline pleurodesis is improved by surgical rather than medical drainage and instillation of sclerosant, 34 patients were prospectively randomised to a trial comparing the two treatment modalities, of whom 29 were evaluable for response. The total failure rate of primary pleurodesis was 13.4%, the rate of recurrence of effusion within the first month was 24%, and only 1 patient (3.4%) required repeat aspiration in that time period. There was no significant difference in the rate of recurrence or reaspiration of effusion between the two treatment groups. Although the overall survival time from treatment of effusion is significantly longer in the surgical treatment group than in the medical treatment group (P = 0.03), this is likely to be due to factors other than the method of treating the effusion. We conclude that surgical tetracycline pleurodesis has no advantage over medical tetracycline pleurodesis. Standard treatment for pleural infection includes catheter drainage and antibiotics. Tube drainage often fails if the fluid is loculated by fibrinous adhesions when surgical drainage is needed. Streptokinase may aid the process of pleural drainage, but there have been no controlled trials to assess its efficacy.
                Twenty four patients with infected community acquired parapneumonic effusions were studied. All had either frankly purulent/culture or Gram stain positive pleural fluid (13 cases; 54%) or fluid which fulfilled the biochemical criteria for pleural infection. Fluid was drained with a 14F catheter. The antibiotics used were cefuroxime and metronidazole or were guided by culture. Subjects were randomly assigned to receive intrapleural streptokinase, 250,000 i.u. daily, or control saline flushes for three days. The primary end points related to the efficacy of pleural drainage--namely, the volume of pleural fluid drained and the chest radiographic response to treatment. Other end points were the number of pleural procedures needed and blood indices of inflammation.
                The streptokinase group drained more pleural fluid both during the days of streptokinase/control treatment (mean (SD) 391 (200) ml versus 124 (44) ml; difference 267 ml, 95% confidence interval (CI) 144 to 390; p < .001) and overall (2564 (1663) ml, 95% CI 465 to 2545; p < 0.01). They showed greater improvement on the chest radiograph at discharge, measured as the fall in the maximum dimension of the pleural collection (6.0 (2.7) cm versus 3.4 (2.7) cm; difference 2.9 cm, 95% CI 0.3 to 4.4; p < 0.05) and the overall reduction in pleural fluid collection size (p < 0.05, two-tailed Fisher's exact test). Systemic fibrinolysis and bleeding complications did not occur. Surgery was required by three control patients but none in the streptokinase group.
                Intrapleural streptokinase probably aids the treatment of pleural infections by improving pleural drainage without causing systemic fibrinolysis or local haemorrhage. To evaluate the feasibility, safety, and tolerance of early removing gastrointestinal decompression and early oral feeding in the patients undergoing surgery for colorectal carcinoma.
                Three hundred and sixteen patients submitted to operations associated with colorectostomy from January 2004 to September 2005 were randomized to two groups: In experimental group (n=161), the nasogastric tube was removed after the operation from 12 to 24 h and was promised immediately oral feeding; In control group (n=155), the nasogastric tube was maintained until the passage of flatus per rectum. Variables assessed included the time to first passage of flatus, the time to first passage of stool, the time elapsed postoperative stay, and postoperative complications such as anastomotic leakage, acute dilation of stomach, wound infection and dehiscense, fever, pulmonary infection and pharyngolaryngitis.
                The median and average days to the first passage of flatus (3.0+/-0.9 vs 3.6+/-1.2, P<0.001), the first passage of stool (4.1+/-1.1 vs 4.8+/-1.4, P<0.001) and the length of postoperative stay (8.4+/-3.4 vs 9.6+/-5.0, P<0.05) were shorter in the experimental group than in the control group. The postoperative complications such as anastomotic leakage (1.24% vs 2.58%), acute dilation of stomach (1.86% vs 0.06%) and wound complications (2.48% vs 1.94%) were similar in the groups, but fever (3.73% vs 9.68%, P<0.05), pulmonary infection (0.62% vs 4.52%, P<0.05) and pharyngolaryngitis (3.11% vs 23.23%, P<0.001) were much more in the control group than in the experimental group.
                The present study shows that application of gastrointestinal decompression after colorectostomy can not effectively reduce postoperative complications. On the contrary, it may increase the incidence rate of fever, pharyngolaryngitis and pulmonary infection. These strategies of early removing gastrointestinal decompression and early oral feeding in the patients undergoing colorectostomy are feasible and safe and associated with reduced postoperative discomfort and can accelerate the return of bowel function and improve rehabilitation. Only 4 controlled trials have investigated whether prophylactic abdominal drainage was of value after colonic resection. None have been able to find any statistically significant difference, but the number of patients was small and the beta error risk was high.
                To compare patients who underwent abdominal drainage with those who did not for the rate and severity of complications after elective colonic resection followed immediately by anastomosis of the suprapromontory colon and to compare suction drains with nonsuction drains.
                Between September 1990 and June 1995, 319 patients (135 men and 184 women), whose mean age was 67 years (range, 22-95 years), with carcinoma, benign tumors, or colitis, located anywhere between the ascending and sigmoid colons, were included in the study. Patients were comparable for demographic characteristics, except that there were more patients with ascites in the group that did not undergo abdominal drainage (P<.02).
                After 2 protocol violations, 156 patients were randomized to the abdominal drainage group and 161 to the no abdominal drainage group. All 317 anastomoses were tested for airtightness intraoperatively and repaired if leakage was found (n=71), and all patients with anastomoses received a routine diatrizoate sodium enema to detect infraclinical leakage.
                The postoperative complications possibly influenced by drainage included (1) deep complications for which drainage can lead to early diagnosis, such as generalized or localized peritonitis, intraabdominal hemorrhage, or hematoma; (2) complications believed to be enhanced by drainage, such as an operative wound (an abscess, disruption, or incisional hernia) or pulmonary (microatelectasis) and intestinal obstructions; and (3) complications directly due to the drains, such as ulcerations leading to fistulae, hemorrhages, drainage tract infections, difficulty in removal, intra-abdominal retention, and incisional disruptions. Subsidiary end points were the severity of these complications as assessed by the number of related subsequent operations and deaths.
                Twenty-six patients overall (8%) had postoperative complications possibly influenced by drainage (9% in the group that underwent abdominal drainage and 8% in the group that did not). This difference was not statistically significant (P<.90). One patient had a fistula directly imputable to drainage. There was no difference between suction and nonsuction drainage (P<.90).
                Routine abdominal drainage after colonic resection and immediate anastomosis decreases neither the rate nor the severity of anastomotic leakage. It can, occasionally, be detrimental. A prospective comparison was made of the clinical courses of two groups of neonates ventilated according to different protocols: one group at rates of 20 to 40/minute with a one-second IT, and the other at a rate of 60/minute and 0.5 second IT. Other ventilator settings were adjusted within protocol limits to maintain desired blood gas values. Mean starting and highest PIP were lower in the rapid rate group. The results showed no difference in mortality, failure to remain within protocol limits, time requiring respiratory treatment or FiO2 more than 0.6, and incidence of PDA or chronic lung disease. There was a difference (P = 0.011) in number of infants developing pneumothoraces (14% in the rapid group vs 35% in the slow group). Rapid rate ventilation can be used to decrease the incidence of pneumothorax, reserving long IT and higher PIP for infants who cannot be oxygenated or ventilated without them. Although increasing evidence suggests that prophylactic drainage after intra-peritoneal colorectal anastomoses is unnecessary, drains for infra-peritoneal rectal anastomoses, where the leak rate is higher, are widely employed still. The aim of this study was to assess the effect of prophylactic drainage after anastomosis below the peritoneal reflection. All patients attending one specialist unit over an 8-month period for elective rectal cancer resection with an infra-peritoneal anastomosis were randomised to drainage or no drainage. The incidence of anastomotic leak and complications specific to the drain as well as other complications were compared. Fifty-nine patients were analysed (31 with drain). Twenty-five of the drained and 16 of the no-drain patients had a defunctioning stoma (p=ns). The groups were comparable for demographic data, operation and anastomotic height from the anal verge. There were three leaks (10%) in the drain group and five leaks (18%) in the no-drain group (p=ns). There were 2 (7%) patients in each group with a clinical leak. There were no specific drain complications and the incidence of other complications was similar in both groups. In conclusion, this study supports the contention that there is no difference in morbidity with or without the use of a drain for infra-peritoneal anastomoses.
There is no significant difference between simple aspiration and intercostal tube drainage with regard to: immediate success rate, early failure rate, duration of hospitalisation, one year success rate and number of patients requiring pleurodesis at one year. Simple aspiration is associated with a reduction in the per cent of patients hospitalized when compared with intercostal tube drainage.