EDITORIAL COMMENT
1
851 RADIOGRAPHIC EVALUATION OF CHEST AFTER FLANK SURGERY There are various approaches for intraoperative manage- ment of pleurotomy. Tube thoracostomy is generally unnec- essary since the visceral pleura is usually not injured. The diaphragm needs to be adequately mobilized to facilitate closure. A 12F rubber catheter is placed in the pleural cavity, and the pleura is closed with a running absorbable suture. Surrounding diaphragm may be incorporated to buttress this suture line. The lung is expanded with positive pressure ventilation and the remaining air is evacuated by direct negative pressure aspiration through the catheter or by plac- ing the tip of the catheter in a fluid filled container. The catheter is removed when no more air can be aspirated or when bubbling ceases in the “water seal device.” The running suture is subsequently tied while the lung is kept expanded with continuous positive pressure ventilation. This approach was used in all of our patients and was successful in 61 of 63 cases (96.8%). Postoperative needle aspiration may be used to expand the lung if a clinically significant pneumothorax is present. Tube thoracostomy is reserved for recognized or suspected injury of the visceral pleura, or failure of the afore- mentioned techniques. Our results demonstrate that routine performance of post- operative chest radiography to assess for pneumothorax is not warranted. The majority of pleural isjuries are recog- nized intraoperatively (61 of 63 in our series). The 2 unrec- ognized pleural injuries in this study were insignificant since the pneumothoraces resolved spontaneously. The cost of de- tecting pneumothorax was $1,676 per patient and $14,250 per patient for symptomatic pneumothorax. Eliminating these x-ray studies would be a cost saving measure since they added $28,500 in charges to our patient cohort, which would be even more prominent when extended to a national level. We calculated that the performance of routine chest radiog- raphy in patients undergoing nephrectomy in the United States would cost $6.9 million a year based on the number of nephrectomies and nephroureterectomies performed in this country in 1992,s our pleurotomy rate and x-ray costs. How- ever, we still believe that postoperative radiography is indi- cated in those patients sustaining incidental pleurotomy. CONCLUSIONS Pleural injury occurs in a significant number of patients subjected to open flank surgery, and rib resection is a major risk factor. This complication is usually recognized intra- operatively and can be rectified by simple measures. The development of pneumothorax due to intraoperative pleural injury is not associated with the development of other com- plications and does not influence postoperative length of hos- pitalization. Routine postoperative chest radiography to as- sess for this problem is unwarranted unless other clinical indications exist. REFERENCES 1. Bodner, D. R. and Resnick, M. I.: Complications of surgery for removal of renal and ureteral stones. In: Urologic Complica- tions: Medical and Surgical, Adult and Pediatric. Edited by F. F. Marshall. St. Louie. Mosby Year Book, Inc., chapt. 11, pp. 182-199,1990. 2. Kwik. R. S.: Complications associated with surgery in the aank p i t i o n for urological pmedures. Middle East J. Anaesthe siol., I: 495,1980. 3. Scott, R. F., Jr. and Selzman, H. M.: Complications of nephrec- tomy: review of 450 patients and a description of a modifica- tion of the transperitoneal approach. J. Urol., 96 307.1966. 4. Hohhead, W. H.: The thorax in general. In: Anatomy for Surgeons. New York Paul B. Hoeber, Inc., vol. 2, pp. 1-39, 1956. 5. King, T. C. and Smith, C. R.: Cheat wall, pleura, lung, and mediastinum. In: Principles of Surgery, 6th ed. Edited by S. I. Schwartz, G. T. Shires and F. C. Spencer. New Ymk McGraw- Hill Book Co., Inc., pp. 659-777,1994. 6. Riehle, R. A, Jr. and Lavengood, R.: An extrapleural approach with rib removal for the eleventh rib flank incision. Surg., Gynec. & Obst., l6l: 276,1985. ‘ogram changes 7. Botz, G. and Bmck-Utne, J. G.: Are e l - the first sign of impending peri-operative pneumothorax? An- aesthesia, 41: 1057,1992. 8. Graves, E. J.: Detailed diagnoses and procedures, National Hos- pital Discharge Survey, 1992. Series 13 Data h m the Na- tional Health Survey. Vital Health Stat., 118: 1.1994. EDITORIAL COMMENT Previously, there has beem little impetus or incentive for physi- cians to examine critically diagnostic studiee commonly accepted as ‘routine.” Noninvasive tests may, in particular, become standard care despite an extremely low yield of clinically meaningful informa- tion. Overuse of a diagnostic test is often prompted by well inten- tioned physician efforta toward being thorough and complete in the care of patients. However, failure to admowledge that fear of mal- practice litigation for omitting a test is ale0 a partial driving force would be naive. I have never routinely obtained a chest x-ray & flank surgery and rarely order one now unless clinical Circumetan ces support the need. In fact, I euepect that few urological aurgeons order chest x-rays atter flank surgery as oRen as the authors of this paper did before their study. Consequently, the extrapolations in amt savings are probably not valid. Nevertheless, there undoubtedly are similar examples in all of our practices of studiea obtained frequently which rarely provide clinically me- information. As managed care inereaeingly reverses the financial incentive for performing teets or procedures, the burden falls upon clinicians to make certain that cost-effectiveness or, worse, mstcompetitiveness does not interfere with optimal patient care. A personal anecdote reminds me of the dilemma we face. My youngest daughter fell on a playground and was knocked uncon- scious. Wen I saw her in the emergency room, she was still quite tiomnolent. The neurosugeoa told me that it was not cost-effective to perform a magnetic resonance image (MRI) for ‘only” a 5% hk of subdural hematoma For my daughter 5% was more than enougb to justify the teet and I threatened that he would be the one needing an MRI if he did not order the acan promptly. The MRI on my daughtar was normal, and 80 I suppose I added unnecessarily to overall health care expenditures. Neither emotion nor financial considerations alone should dictate treatment policies. As far as possible, a critical review of available data should establish standards and guidelines for patient care. Joseph A Smith, Jr. Department of urrolqgy Vanderbilt University Medid Schaol Nashville, Tennessee
Transcript of EDITORIAL COMMENT
851 RADIOGRAPHIC EVALUATION OF CHEST AFTER FLANK SURGERY
There are various approaches for intraoperative manage- ment of pleurotomy. Tube thoracostomy is generally unnec- essary since the visceral pleura is usually not injured. The diaphragm needs to be adequately mobilized to facilitate closure. A 12F rubber catheter is placed in the pleural cavity, and the pleura is closed with a running absorbable suture. Surrounding diaphragm may be incorporated to buttress this suture line. The lung is expanded with positive pressure ventilation and the remaining air is evacuated by direct negative pressure aspiration through the catheter or by plac- ing the tip of the catheter in a fluid filled container. The catheter is removed when no more air can be aspirated or when bubbling ceases in the “water seal device.” The running suture is subsequently tied while the lung is kept expanded with continuous positive pressure ventilation. This approach was used in all of our patients and was successful in 61 of 63 cases (96.8%). Postoperative needle aspiration may be used to expand the lung if a clinically significant pneumothorax is present. Tube thoracostomy is reserved for recognized or suspected injury of the visceral pleura, or failure of the afore- mentioned techniques.
Our results demonstrate that routine performance of post- operative chest radiography to assess for pneumothorax is not warranted. The majority of pleural isjuries are recog- nized intraoperatively (61 of 63 in our series). The 2 unrec- ognized pleural injuries in this study were insignificant since the pneumothoraces resolved spontaneously. The cost of de- tecting pneumothorax was $1,676 per patient and $14,250 per patient for symptomatic pneumothorax. Eliminating these x-ray studies would be a cost saving measure since they added $28,500 in charges to our patient cohort, which would be even more prominent when extended to a national level. We calculated that the performance of routine chest radiog- raphy in patients undergoing nephrectomy in the United States would cost $6.9 million a year based on the number of nephrectomies and nephroureterectomies performed in this country in 1992,s our pleurotomy rate and x-ray costs. How- ever, we still believe that postoperative radiography is indi- cated in those patients sustaining incidental pleurotomy.
CONCLUSIONS
Pleural injury occurs in a significant number of patients subjected to open flank surgery, and rib resection is a major risk factor. This complication is usually recognized intra- operatively and can be rectified by simple measures. The development of pneumothorax due to intraoperative pleural injury is not associated with the development of other com- plications and does not influence postoperative length of hos- pitalization. Routine postoperative chest radiography to as- sess for this problem is unwarranted unless other clinical indications exist.
REFERENCES
1. Bodner, D. R. and Resnick, M. I.: Complications of surgery for removal of renal and ureteral stones. In: Urologic Complica- tions: Medical and Surgical, Adult and Pediatric. Edited by F. F. Marshall. St. Louie. Mosby Year Book, Inc., chapt. 11, pp. 182-199,1990.
2. Kwik. R. S.: Complications associated with surgery in the aank p i t i o n for urological pmedures. Middle East J. Anaesthe siol., I: 495, 1980.
3. Scott, R. F., Jr. and Selzman, H. M.: Complications of nephrec- tomy: review of 450 patients and a description of a modifica- tion of the transperitoneal approach. J. Urol., 9 6 307.1966.
4. H o h h e a d , W. H.: The thorax in general. In: Anatomy for Surgeons. New York Paul B. Hoeber, Inc., vol. 2, pp. 1-39, 1956.
5. King, T. C. and Smith, C. R.: Cheat wall, pleura, lung, and mediastinum. In: Principles of Surgery, 6th ed. Edited by S. I. Schwartz, G. T. Shires and F. C. Spencer. New Ymk McGraw- Hill Book Co., Inc., pp. 659-777, 1994.
6. Riehle, R. A, Jr. and Lavengood, R.: An extrapleural approach with rib removal for the eleventh rib flank incision. Surg., Gynec. & Obst., l6l: 276,1985.
‘ogram changes 7. Botz, G. and Bmck-Utne, J. G.: Are el- the first sign of impending peri-operative pneumothorax? An- aesthesia, 41: 1057, 1992.
8. Graves, E. J.: Detailed diagnoses and procedures, National Hos- pital Discharge Survey, 1992. Series 13 Data h m the Na- tional Health Survey. Vital Health Stat., 118: 1.1994.
EDITORIAL COMMENT Previously, there has beem little impetus or incentive for physi-
cians to examine critically diagnostic studiee commonly accepted as ‘routine.” Noninvasive tests may, in particular, become standard care despite an extremely low yield of clinically meaningful informa- tion. Overuse of a diagnostic test is often prompted by well inten- tioned physician efforta toward being thorough and complete in the care of patients. However, failure to admowledge that fear of mal- practice litigation for omitting a test is ale0 a partial driving force would be naive.
I have never routinely obtained a chest x-ray & flank surgery and rarely order one now unless clinical Circumetan ces support the need. In fact, I euepect that few urological aurgeons order chest x-rays atter flank surgery as oRen as the authors of this paper did before their study. Consequently, the extrapolations in amt savings are probably not valid. Nevertheless, there undoubtedly are similar examples in all of our practices of studiea obtained frequently which rarely provide clinically me- information. As managed care inereaeingly reverses the financial incentive for performing teets or procedures, the burden falls upon clinicians to make certain that cost-effectiveness or, worse, mstcompetitiveness does not interfere with optimal patient care. A personal anecdote reminds me of the dilemma we face. My
youngest daughter fell on a playground and was knocked uncon- scious. W e n I saw her in the emergency room, she was still quite tiomnolent. The neurosugeoa told me that it was not cost-effective to perform a magnetic resonance image (MRI) for ‘only” a 5% h k of subdural hematoma For my daughter 5% was more than enougb to justify the teet and I threatened that he would be the one needing an MRI if he did not order the acan promptly. The MRI on my daughtar was normal, and 80 I suppose I added unnecessarily to overall health care expenditures.
Neither emotion nor financial considerations alone should dictate treatment policies. As far as possible, a critical review of available data should establish standards and guidelines for patient care.
Joseph A Smith, Jr. Department of urrolqgy Vanderbilt University M e d i d Schaol Nashville, Tennessee
