Transhiatal chest drainage in transmediastinal esophagectomy effectively evacuated pleural effusion and significantly reduced the frequency of postoperative thoracentesis, which carries the risk of iatrogenic pneumothorax. In addition, the transhiatal chest drainage system did not employ an underwater seal but a portable vacuum system, which was reportedly easy to insert and safe in terms of other complications. To date, we know of no studies that have discussed the suitability of an indwelling transhiatal chest drainage tube in transmediastinal esophagectomy. This is the first study we know of to assess the effective and safe evacuation of pleural effusion via intraoperative placement of a chest drainage tube in transmediastinal esophagectomy.
A single Blake drain inserted through the abdominal wall effectively evacuated pleural effusion in this study. The utility of a mediastinal drainage tube from the abdominal wall through the hiatus after thoracic esophagectomy has recently been reported . Transhiatal chest drainage using a Blake drain has also been reported to be effective and safe in Ivor Lewis esophagectomy . The insertion of a chest drainage tube intraoperatively via the intercostal space is difficult in transmediastinal esophagectomy, and in such cases, transhiatal chest drainage is appropriate. Additionally, the use of a portable vacuum system connected to the Blake drain is a viable alternative to the underwater seal [6, 10, 11]. A single Blake drain inserted from the right intercostal space into the left thoracic cavity across the mediastinum is useful for drainage of the left pleural effusion after thoracic esophagectomy . The transhiatal chest drainage in transmediastinal esophagectomy has similar effects to these drainage systems.
The placement of the transhiatal chest drainage tube was a simple procedure, which was completed in <6 min. Despite not being able to control the drain tip position from the transabdominal view, pleural effusion was evacuated effectively. However, the adequate duration of drainage after surgery was unclear in this study. In the non-drainage group, thoracentesis was required until POD 2. In the drainage group, median volume of drainage output decreased to <200 mL after POD 5. In addition, the amount of transhiatal drainage might be attributed not only to pleural effusion but also to ascites. The indwelling period for the drainage tube could potentially be shortened. Despite other studies describing the use of a 15-Fr drain, we used a 19-Fr drain [6, 12]. The 15-Fr drain is more beneficial than the 19-Fr one in terms of preventing dislocation, excessive drainage, and pain caused to patients . Further clinical experiences are needed to clarify the appropriate duration of drainage and drain size.
This study had some limitations. First, this study was a retrospective analysis with a small sample size; thus, the characteristics of patients, such as sex and the decision for drain placement were not homogenous, and selection bias is possible. Second, this study did not compare transhiatal chest drainage with conventional thoracic drainage. However, the inferiority of thoracic drainage might be definitive in terms of the difficulty of the thoracic approach in transmediastinal esophagectomy. Third, the diagnosis of pleural effusion and necessity for thoracentesis were decided by the attending physician. Evaluations associated with oxygenation, such as the duration of oxygen administration, respiratory complications, and postoperative hospital stay, did not differ significantly between the two groups. Further studies are required to validate these findings.