title: Tube Thoracostomy at the Time of Congenital Diaphragmatic Hernia Repair: Reassessing the Risks and Benefits.
abstract: OBJECTIVE
  Postoperative pneumothorax and effusion remain a concern following congenital diaphragmatic hernia (CDH) repair. Despite a recent trend away from intraoperative thoracostomy, few studies have actually compared outcomes with and without a chest tube. Rationale commonly cited for the more minimalistic approach include the presumed low likelihood of postoperative complications, potential risk of patch infection, and prolonged intubation. We evaluate these theories, as well as the implications of intraoperative chest tube (IOCT) placement.
  
  
  METHODS
  We performed a retrospective chart review of 174 patients who underwent CDH repair at our academic children's hospital from 2004 to 2015. We compared incidence of clinically significant pleural events between patients who received an IOCT (n = 49) and those who did not (NIOCT, n = 124). We also evaluated time to extubation and rate of patch infections.
  
  
  RESULTS
  Clinically significant pneumothorax or effusion occurred in 28% of NIOCT patients versus 10% of IOCT patients (P = .01). After thoracoscopic repair, time to extubation averaged 5.2 days in IOCT patients, 5.4 days in NIOCT patients with no postoperative complications, and 6.4 days in NIOCT patients requiring postoperative intervention. After open repair, time to extubation averaged 13.8, 13.6, and 22.5 days, respectively. There were no documented patch infections.
  
  
  CONCLUSIONS
  Chest tube placement during CDH repair is associated with significantly lower incidence of clinically significant pleural complications, does not delay extubation, and results in shorter ventilator times than cases that require postoperative intervention. Patch infections are extremely rare. There is no evidence that chest tube placement increases this risk.
authors.affiliation: 1 Akron Children's Hospital , Department of Surgery, Akron, Ohio.
authors.forename: Avraham
authors.initials: A
authors.lastname: Schlager
authors.affiliation: 2 Emory University/Children's Healthcare of Atlanta , Department of Surgery, Atlanta, Georgia .
authors.forename: Kelly
authors.initials: K
authors.lastname: Arps
authors.affiliation: 3 Oregon Health and Science University , Department of Surgery, Portland, Oregon.
authors.forename: Ragavan
authors.initials: R
authors.lastname: Siddharthan
authors.affiliation: 2 Emory University/Children's Healthcare of Atlanta , Department of Surgery, Atlanta, Georgia .
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Clifton
mesh_terms: D015505:Chest Tubes; D005260:Female; D005500:Follow-Up Studies; D065630:Hernias, Diaphragmatic, Congenital / Q000601:surgery*; D059685:Herniorrhaphy; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010996:Pleural Effusion / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D011030:Pneumothorax / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D012189:Retrospective Studies; D018570:Risk Assessment; D013907:Thoracostomy / Q000295:instrumentation; D016896:Treatment Outcome
keywords: chest tube; congenital diaphragmatic hernia; postoperative pleural effusion; postoperative pneumothorax; tube thoracostomy