Early removal of chest drainage after videothoracoscopic lung biopsy
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《血管的通路杂志》
Sagrat Cor University Hospital, Thoracic Surgery Department, Viladomat 288, 08029 Barcelona, Spain
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
Abstract
We report our experience with a policy of early chest tube removal after video-assisted thoracic surgical lung biopsy (VATS-LB) in 146 patients. The chest tube (24F) was removed if four conditions were met: immediate extubation, complete expansion of the lung, drainage <100 ml/h and absence of an air leak. VATS-LB was performed on 160 patients. In 146 (91.2%) early chest tube removal was feasible. Fourteen (8.8%) were too ill to be included in this program. The chest tube was removed in 135 patients (92.4%) less than one hour after. In nine patients (6.2%) it was removed 4–24 h after, due to initial air-leak. In only two cases (1.4%) was the tube removed later. Median hospital stay was 1.2 days (range: 0–7). There were 32 outpatient procedures since 2001 (50% of VATS-LB in this period). Postoperative hemothorax occurred in two patients (1.4%) and pneumothorax in three (2.0%). Three of the five required readmission (2%). Three patients died in the hospital due to the progression of their illness. In the absence of postoperative air-leak, early chest tube removal after VATS-LB appears to be safe, reduces hospital stay and allows an outpatient procedure in selected cases.
Key Words: Biopsy; Endoscopy; Lung pathology; Video-assisted thoracic surgery (VATS)
1. Introduction
Lung biopsies are essential for the accurate diagnosis and treatment of diffuse interstitial lung diseases [1]. Video-assisted thoracic surgical lung biopsy (VATS-LB) has become an increasingly accepted approach for the diagnosis of these patients [2]. The usual approach to chest tube management after VATS-LB involves a period of applied suction followed by water seal drainage before chest tube removal. Despite recent reports demonstrating the safety of early chest tube removal in patients undergoing VATS-LB, patients are typically admitted for mean postoperative stays of 1–3 days or even longer, up to one week [3]. This strategy was developed over many years for patients undergoing a major pulmonary resection through thoracotomy incisions, and it is indeed the cause of prolonged postoperative stays [4]. The development of VATS with modern surgical endostaplers and an accurate surgical technique for reducing lung trauma, permits minimization of the risk of postoperative air-leaks. For these reasons we believe in the safety and feasibility of early chest tube removal after VATS wedge resection of peripherally located pulmonary parenchymal disease. In this study we report our experience with the early removal of chest drainage after VATS-LB.
2. Materials and methods
From January 1992 to January 2004, 160 patients underwent VATS wedge resection for interstitial lung disease. Prior to surgery, all patients underwent preoperative chest computed tomographic scanning (CT) and pulmonary function tests. There was no upper age limiting patient selection. Patients who were oxygen dependent, hospitalized for acute illness or had a FEV1 <30% were not considered for entering early chest tube removal protocol. Approval of the study was obtained from the Institutional Ethics Committee. The surgical procedure was performed under general anesthesia with a double-lumen endotracheal tube or by selective bronchial intubation using a single lumen tube. With the patient in the lateral decubitus position, three port sites, including one for a 10-mm 0° videothoracoscope were used and one or two wedge resections following the CT and the direct view of the lung were performed. All wedge resections were performed using endostaplers of 3.5-mm. Unnecessary grasping of the lung with instruments was avoided; this minimized lung trauma and iatrogenic air leak. The lung was grasped once with a lung endo-clamp and a stapled wedge resection was done with a linear stapler. Butressing of the staple line was not done. The integrity of the parenchymal staple line and surrounding visceral pleura were then assessed by reinflating the lung. Local anesthetic (0.5% bupivacaine with adrenaline, or 0.2% ropivacaine) was systematically infiltrated into the intercostal spaces. Dependent pleural drainage was obtained with a single 24F chest tube placed to –15 cm H2O suction at the conclusion of each procedure. Chest tubes were removed in the recovery room if the following criteria were met: immediate extubation, complete expansion of the lung on postoperative chest X-ray, drainage <100 ml/h and absence of an air-leak. Since 2001 patients were discharged with an oral analgesic on the day of operation. Patient follow-up was obtained from a postoperative visit and a chest X-ray within 1 week post-VATS-LB, and thereafter by reviewing clinical records.
3. Results
One hundred and forty-six patients (out of 160, 91.2%) were considered for early chest tube removal protocol. The mean age was 61 years (range: 25–80). Fourteen patients (8.8%) were too ill to be included in the program (oxygen dependent, hospitalized for acute illness or FEV1 <30%). Chest tube removal timing is shown in Table 1: one hour after VATS-LB, 135 patients (92.4%); from 4 to 24 h: 9 patients (6.2%), because of initial air-leaks. After forty-eight hours or longer, 2 patients (1.4%): one patient due to a postoperative hemothorax and the other because of a persistent air-leak. Median stay was 1.2 days (range: 0–7). Since 2001 VATS-LBs were performed as an outpatient procedure in 32 patients (50% of all VATS-LB in this period). Postoperative complications in the whole group are shown in Table 2: hemothorax, 2 patients (1.4%), (one case was observed immediately after surgery and the other hemothorax case was diagnosed during the ambulatory visit 7 days after surgery and required a chest tube and readmission). Pneumothorax, 3 patients (2%); one case was observed after surgery and one case was diagnosed in the chest X-ray during the ambulatory visit requiring a chest tube and readmission. The third case was diagnosed and treated in another medical center and also required chest tube and admission. Three patients (2%) died in the hospital due to progression of their Hamman-Rich syndrome (not related to the VATS-LB). A pathologic diagnosis was established in all patients. Treatment of diffuse interstitial lung disease and long-term clinical follow-up was done by referring pulmonary physicians.
4. Discussion
Surgical lung biopsy has become an important tool to assist physicians in determining the optimal medical therapy for patients with interstitial lung disease [1]. Thoracotomy and open lung biopsy have been standard surgical approaches for many years, however, VATS-LB has demonstrated itself to be a valid alternative to the open approach in most cases. Along with a comparable efficacy, VATS-LB has advantages that make it the method of choice [5]. More than 10 years ago, Molin and coworkers compared patients with interstitial lung disease who had been submitted to lung biopsy with either VATS or open thoracotomy. They concluded that lung biopsy could be performed safely and efficiently with both techniques, but VATS resulted in higher procedure-related costs [6].
However, despite its costs, VATS-LBs are mostly reported to result in less chest wall trauma than traditional thoracotomy, and the incidence of pulmonary parenchymal air-leaks appears to be small with the use of modern endoscopic stapling devices.
Therefore, it is reasonable to consider early chest tube removal after VATS wedge resection of peripherally located pulmonary parenchymal disease as a feasible procedure.
Russo and colleagues suggested that patients undergoing elective VATS lung biopsy for diagnosis of either pulmonary nodules of interstitial lung disease could be considered for early chest tube removal [7]. In a prospective, nonrandomized trial including 59 patients they demonstrated that chest tube removal within 90 min of VATS lung biopsy, in selected patients, could be accomplished safely. In addition, they reported a consequent reduction in analgesic requirements, without apparent increase in complications, particularly pneumothorax, when compared with patients undergoing traditional management of chest tubes. Further, when compared with the control group, in which mean postoperative hospitalization was nearly 4 days, patients with early removal of chest tubes had significantly shorter mean postoperative hospitalization of 2 days. In our series the mean postoperative stay was 1.2 days. In another study, Blewett and coworkers did not use chest tube drainage after open lung biopsy for diagnosis of interstitial lung disease in 32 patients [8]. No complications occurred and no patients required overnight observation or hospital admission.
Despite these works, the majority of thoracic surgeons remain wedded to the chest tube removal timing policy common for open pulmonary resections. Even in groups employing experimental and advanced VATS-LB techniques (butressing of stapled line, YAG laser, harmonic scalpel, etc), chest tube removal is delayed [9–11]. In fact most surgeons opt to leave the chest tube in place for up to 24 h or even longer to guard against postoperative complications such as retained hemothorax or pneumothorax. In our reply to Molnar and coworkers we explain our policy of early chest tube removal and consequently early discharge from the hospital [12].
While it is true that sometimes significant drainage is seen when the tube remains in place for longer periods, it is also true that the removal of a chest tube after a drainage of even 350 cc has been recommended [13]. Our own clinical findings do not support the delay in chest tube removal. Our results show that chest tubes can be safely removed shortly after operation if certain criteria are met: immediate extubation, complete expansion of the lung on postoperative chest X-ray, drainage <100 ml/h and absence of an air leak. In our series we perfomed early removal of chest drainage (1 h after VATS-LB) in 92.4% (135 out of 146 patients) with a complication rate of hemothorax or pneumothorax of 3.4%.
Chang and coworkers reported a series of 62 ambulatory patients undergoing outpatient thoracoscopic lung biopsy with early chest tube removal [14]. A total of 72.5% were discharged home within 8 h of observation on the day of operation, 22.5% were discharged within 23 h of their operation and 5% required admission for prolonged air-leak or conversion to muscle-sparing thoracotomy; one patient was readmitted for pneumothorax. They concluded that early chest tube removal and outpatient thoracoscopic lung biopsy were safe and effective. In our published series of day-case thoracic surgery, starting from 2001, most patients to whom lung biopsy was performed were discharged within 4 h of their operation and only one patient required admission due to air-leak observed before chest tube withdrawal [15].
To our knowledge this is the largest series to date (146 patients) of early chest tube removal after VATS-LB and according to our results we believe that in the absence of postoperative air leak, early chest tube removal after VATS-LB appears to be safe, reduces hospital stay and allows an outpatient procedure in selected cases.
References
British Thoracic Society recommendations. The diagnosis, assessment and treatment of diffuse parenchymal lung disease in adults. Thorax 1999; 54:S1–S30.
Rena O, Casadio C, Leo F, Giobbe R, Cianci R, Baldi S, Rapellino M, Maggi G. Videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg 1999; 16:624–627.
Miller JD, Urschel JD, Cox G, Olak J, Young JE, Kay JM, McDonald E. A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease. Ann Thorac Surg 2000; 70:1647–1650.
Kramer MR, Berkman N, Mintz B, Godfrey S, Saute M, Amir G. The role of open lung biopsy in the management and outcome of patients with diffuse lung disease. Ann Thorac Surg 1998; 65:198–202.
Mouroux J, Clary-Meinesz C, Padovani B, Perrin C, Rotomondo C, Chavaillon JM, Blaive B, Richelme H. Efficacy and safety of videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg 1997; 11:22–24. 25–26.
Molin LJ, Steinberg JB, Lanza LA. VATS increased costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg 1994; 58:1595–1598.
Russo L, Wiechmann RJ, Magovern JA, Szydlowski GW, Mack MJ, Naunheim KS, Landreneau RJ. Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Ann Thorac Surg 1998; 66:1751–1754.
Blewett CJ, Bennett WF, Miller JD, Urschel JD. Open lung biopsy as an outpatient procedure. Ann Thorac Surg 2001; 71:1113–1135.
Yim AP, Rendina EA, Hazelrigg SR, Chow LT, Lee TW, Wan S, Arifi AA. A new technological approach to nonanatomical pulmonary resection: saline enhanced thermal sealing. Ann Thorac Surg 2002; 74:1671–1676.
Molnar TF, Lukacs L, Rendky Sz, Horvath OP. Improvement of air tightness of stapled lung parenchyma using fascia lata. Interact Cardivasc Thorac Surg 2003; 2:503–505.
Molnar TF, Benko I, Szanto Z, Laszlo T, Horvath OP. Lung biopsy using harmonic scalpel: a randomised single institution study. Eur J Cardiothorac Surg 2005; 28:604–606.
Fibla J, Molins L, Perez J, Vidal G. Early removal of chest drainage and outpatient program after VATS lung biopsy. Eur J Cardiothorac Surg 2006; 29:639–640.
Cerfolio RJ. Chest tube management after pulmonary resection. Chest Surg Clin N Am 2002; 12:507–527.
Chang AC, Yee J, Orringer MB, Iannettoni MD. Diagnostic thoracoscopic lung biopsy: an outpatient experience. Ann Thorac Surg 2002; 74:1942–1946.
Molins L, Fibla J, Perez J, Sierra A, Vidal G, Simon C. Outpatient thoracic surgical program in 300 patients; clinical results and economical impact. Eur J Cardiothorac Surg 2006; 29:271–275.(Juan J. Fibla, Laureano M)
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
Abstract
We report our experience with a policy of early chest tube removal after video-assisted thoracic surgical lung biopsy (VATS-LB) in 146 patients. The chest tube (24F) was removed if four conditions were met: immediate extubation, complete expansion of the lung, drainage <100 ml/h and absence of an air leak. VATS-LB was performed on 160 patients. In 146 (91.2%) early chest tube removal was feasible. Fourteen (8.8%) were too ill to be included in this program. The chest tube was removed in 135 patients (92.4%) less than one hour after. In nine patients (6.2%) it was removed 4–24 h after, due to initial air-leak. In only two cases (1.4%) was the tube removed later. Median hospital stay was 1.2 days (range: 0–7). There were 32 outpatient procedures since 2001 (50% of VATS-LB in this period). Postoperative hemothorax occurred in two patients (1.4%) and pneumothorax in three (2.0%). Three of the five required readmission (2%). Three patients died in the hospital due to the progression of their illness. In the absence of postoperative air-leak, early chest tube removal after VATS-LB appears to be safe, reduces hospital stay and allows an outpatient procedure in selected cases.
Key Words: Biopsy; Endoscopy; Lung pathology; Video-assisted thoracic surgery (VATS)
1. Introduction
Lung biopsies are essential for the accurate diagnosis and treatment of diffuse interstitial lung diseases [1]. Video-assisted thoracic surgical lung biopsy (VATS-LB) has become an increasingly accepted approach for the diagnosis of these patients [2]. The usual approach to chest tube management after VATS-LB involves a period of applied suction followed by water seal drainage before chest tube removal. Despite recent reports demonstrating the safety of early chest tube removal in patients undergoing VATS-LB, patients are typically admitted for mean postoperative stays of 1–3 days or even longer, up to one week [3]. This strategy was developed over many years for patients undergoing a major pulmonary resection through thoracotomy incisions, and it is indeed the cause of prolonged postoperative stays [4]. The development of VATS with modern surgical endostaplers and an accurate surgical technique for reducing lung trauma, permits minimization of the risk of postoperative air-leaks. For these reasons we believe in the safety and feasibility of early chest tube removal after VATS wedge resection of peripherally located pulmonary parenchymal disease. In this study we report our experience with the early removal of chest drainage after VATS-LB.
2. Materials and methods
From January 1992 to January 2004, 160 patients underwent VATS wedge resection for interstitial lung disease. Prior to surgery, all patients underwent preoperative chest computed tomographic scanning (CT) and pulmonary function tests. There was no upper age limiting patient selection. Patients who were oxygen dependent, hospitalized for acute illness or had a FEV1 <30% were not considered for entering early chest tube removal protocol. Approval of the study was obtained from the Institutional Ethics Committee. The surgical procedure was performed under general anesthesia with a double-lumen endotracheal tube or by selective bronchial intubation using a single lumen tube. With the patient in the lateral decubitus position, three port sites, including one for a 10-mm 0° videothoracoscope were used and one or two wedge resections following the CT and the direct view of the lung were performed. All wedge resections were performed using endostaplers of 3.5-mm. Unnecessary grasping of the lung with instruments was avoided; this minimized lung trauma and iatrogenic air leak. The lung was grasped once with a lung endo-clamp and a stapled wedge resection was done with a linear stapler. Butressing of the staple line was not done. The integrity of the parenchymal staple line and surrounding visceral pleura were then assessed by reinflating the lung. Local anesthetic (0.5% bupivacaine with adrenaline, or 0.2% ropivacaine) was systematically infiltrated into the intercostal spaces. Dependent pleural drainage was obtained with a single 24F chest tube placed to –15 cm H2O suction at the conclusion of each procedure. Chest tubes were removed in the recovery room if the following criteria were met: immediate extubation, complete expansion of the lung on postoperative chest X-ray, drainage <100 ml/h and absence of an air-leak. Since 2001 patients were discharged with an oral analgesic on the day of operation. Patient follow-up was obtained from a postoperative visit and a chest X-ray within 1 week post-VATS-LB, and thereafter by reviewing clinical records.
3. Results
One hundred and forty-six patients (out of 160, 91.2%) were considered for early chest tube removal protocol. The mean age was 61 years (range: 25–80). Fourteen patients (8.8%) were too ill to be included in the program (oxygen dependent, hospitalized for acute illness or FEV1 <30%). Chest tube removal timing is shown in Table 1: one hour after VATS-LB, 135 patients (92.4%); from 4 to 24 h: 9 patients (6.2%), because of initial air-leaks. After forty-eight hours or longer, 2 patients (1.4%): one patient due to a postoperative hemothorax and the other because of a persistent air-leak. Median stay was 1.2 days (range: 0–7). Since 2001 VATS-LBs were performed as an outpatient procedure in 32 patients (50% of all VATS-LB in this period). Postoperative complications in the whole group are shown in Table 2: hemothorax, 2 patients (1.4%), (one case was observed immediately after surgery and the other hemothorax case was diagnosed during the ambulatory visit 7 days after surgery and required a chest tube and readmission). Pneumothorax, 3 patients (2%); one case was observed after surgery and one case was diagnosed in the chest X-ray during the ambulatory visit requiring a chest tube and readmission. The third case was diagnosed and treated in another medical center and also required chest tube and admission. Three patients (2%) died in the hospital due to progression of their Hamman-Rich syndrome (not related to the VATS-LB). A pathologic diagnosis was established in all patients. Treatment of diffuse interstitial lung disease and long-term clinical follow-up was done by referring pulmonary physicians.
4. Discussion
Surgical lung biopsy has become an important tool to assist physicians in determining the optimal medical therapy for patients with interstitial lung disease [1]. Thoracotomy and open lung biopsy have been standard surgical approaches for many years, however, VATS-LB has demonstrated itself to be a valid alternative to the open approach in most cases. Along with a comparable efficacy, VATS-LB has advantages that make it the method of choice [5]. More than 10 years ago, Molin and coworkers compared patients with interstitial lung disease who had been submitted to lung biopsy with either VATS or open thoracotomy. They concluded that lung biopsy could be performed safely and efficiently with both techniques, but VATS resulted in higher procedure-related costs [6].
However, despite its costs, VATS-LBs are mostly reported to result in less chest wall trauma than traditional thoracotomy, and the incidence of pulmonary parenchymal air-leaks appears to be small with the use of modern endoscopic stapling devices.
Therefore, it is reasonable to consider early chest tube removal after VATS wedge resection of peripherally located pulmonary parenchymal disease as a feasible procedure.
Russo and colleagues suggested that patients undergoing elective VATS lung biopsy for diagnosis of either pulmonary nodules of interstitial lung disease could be considered for early chest tube removal [7]. In a prospective, nonrandomized trial including 59 patients they demonstrated that chest tube removal within 90 min of VATS lung biopsy, in selected patients, could be accomplished safely. In addition, they reported a consequent reduction in analgesic requirements, without apparent increase in complications, particularly pneumothorax, when compared with patients undergoing traditional management of chest tubes. Further, when compared with the control group, in which mean postoperative hospitalization was nearly 4 days, patients with early removal of chest tubes had significantly shorter mean postoperative hospitalization of 2 days. In our series the mean postoperative stay was 1.2 days. In another study, Blewett and coworkers did not use chest tube drainage after open lung biopsy for diagnosis of interstitial lung disease in 32 patients [8]. No complications occurred and no patients required overnight observation or hospital admission.
Despite these works, the majority of thoracic surgeons remain wedded to the chest tube removal timing policy common for open pulmonary resections. Even in groups employing experimental and advanced VATS-LB techniques (butressing of stapled line, YAG laser, harmonic scalpel, etc), chest tube removal is delayed [9–11]. In fact most surgeons opt to leave the chest tube in place for up to 24 h or even longer to guard against postoperative complications such as retained hemothorax or pneumothorax. In our reply to Molnar and coworkers we explain our policy of early chest tube removal and consequently early discharge from the hospital [12].
While it is true that sometimes significant drainage is seen when the tube remains in place for longer periods, it is also true that the removal of a chest tube after a drainage of even 350 cc has been recommended [13]. Our own clinical findings do not support the delay in chest tube removal. Our results show that chest tubes can be safely removed shortly after operation if certain criteria are met: immediate extubation, complete expansion of the lung on postoperative chest X-ray, drainage <100 ml/h and absence of an air leak. In our series we perfomed early removal of chest drainage (1 h after VATS-LB) in 92.4% (135 out of 146 patients) with a complication rate of hemothorax or pneumothorax of 3.4%.
Chang and coworkers reported a series of 62 ambulatory patients undergoing outpatient thoracoscopic lung biopsy with early chest tube removal [14]. A total of 72.5% were discharged home within 8 h of observation on the day of operation, 22.5% were discharged within 23 h of their operation and 5% required admission for prolonged air-leak or conversion to muscle-sparing thoracotomy; one patient was readmitted for pneumothorax. They concluded that early chest tube removal and outpatient thoracoscopic lung biopsy were safe and effective. In our published series of day-case thoracic surgery, starting from 2001, most patients to whom lung biopsy was performed were discharged within 4 h of their operation and only one patient required admission due to air-leak observed before chest tube withdrawal [15].
To our knowledge this is the largest series to date (146 patients) of early chest tube removal after VATS-LB and according to our results we believe that in the absence of postoperative air leak, early chest tube removal after VATS-LB appears to be safe, reduces hospital stay and allows an outpatient procedure in selected cases.
References
British Thoracic Society recommendations. The diagnosis, assessment and treatment of diffuse parenchymal lung disease in adults. Thorax 1999; 54:S1–S30.
Rena O, Casadio C, Leo F, Giobbe R, Cianci R, Baldi S, Rapellino M, Maggi G. Videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg 1999; 16:624–627.
Miller JD, Urschel JD, Cox G, Olak J, Young JE, Kay JM, McDonald E. A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease. Ann Thorac Surg 2000; 70:1647–1650.
Kramer MR, Berkman N, Mintz B, Godfrey S, Saute M, Amir G. The role of open lung biopsy in the management and outcome of patients with diffuse lung disease. Ann Thorac Surg 1998; 65:198–202.
Mouroux J, Clary-Meinesz C, Padovani B, Perrin C, Rotomondo C, Chavaillon JM, Blaive B, Richelme H. Efficacy and safety of videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg 1997; 11:22–24. 25–26.
Molin LJ, Steinberg JB, Lanza LA. VATS increased costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg 1994; 58:1595–1598.
Russo L, Wiechmann RJ, Magovern JA, Szydlowski GW, Mack MJ, Naunheim KS, Landreneau RJ. Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Ann Thorac Surg 1998; 66:1751–1754.
Blewett CJ, Bennett WF, Miller JD, Urschel JD. Open lung biopsy as an outpatient procedure. Ann Thorac Surg 2001; 71:1113–1135.
Yim AP, Rendina EA, Hazelrigg SR, Chow LT, Lee TW, Wan S, Arifi AA. A new technological approach to nonanatomical pulmonary resection: saline enhanced thermal sealing. Ann Thorac Surg 2002; 74:1671–1676.
Molnar TF, Lukacs L, Rendky Sz, Horvath OP. Improvement of air tightness of stapled lung parenchyma using fascia lata. Interact Cardivasc Thorac Surg 2003; 2:503–505.
Molnar TF, Benko I, Szanto Z, Laszlo T, Horvath OP. Lung biopsy using harmonic scalpel: a randomised single institution study. Eur J Cardiothorac Surg 2005; 28:604–606.
Fibla J, Molins L, Perez J, Vidal G. Early removal of chest drainage and outpatient program after VATS lung biopsy. Eur J Cardiothorac Surg 2006; 29:639–640.
Cerfolio RJ. Chest tube management after pulmonary resection. Chest Surg Clin N Am 2002; 12:507–527.
Chang AC, Yee J, Orringer MB, Iannettoni MD. Diagnostic thoracoscopic lung biopsy: an outpatient experience. Ann Thorac Surg 2002; 74:1942–1946.
Molins L, Fibla J, Perez J, Sierra A, Vidal G, Simon C. Outpatient thoracic surgical program in 300 patients; clinical results and economical impact. Eur J Cardiothorac Surg 2006; 29:271–275.(Juan J. Fibla, Laureano M)