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doi:10.1510/icvts.2008.188086

Interactive CardioVascular and Thoracic Surgery 8 (2009) 58–61

� 2009 Published by European Association for Cardio-Thoracic Surgery

Institutional report - Thoracic general

The use of Blake drains following general thoracic surgery:is it an acceptable option?

Hiroshige Nakamura*, Yuji Taniguchi, Ken Miwa, Yoshin Adachi, Shinji Fujioka, Tomohiro Haruki

Division of General Thoracic Surgery, Tottori University Hospital, 36-1 Nishi-cho, Yonago, Tottori 683-8504, Japan

Received 11 July 2008; received in revised form 10 September 2008; accepted 16 September 2008

Abstract

As a method of chest drainage, we analyzed the extended utility of silastic flexible drains (Blake drains, Ethicon, Inc., Somerville, NJ)for general thoracic surgery. In 420 cases of general thoracic surgery, Blake drains were used. To examine the utility of Blake drains, weinvestigated the diseases for which they were used, their effectiveness in addressing postoperative complications. The treated diseases forwhich Blake drains were used comprised 181 cases of primary lung cancer, 44 cases of metastatic lung tumor, 57 cases of benign lungdisease, 32 cases of mediastinal tumor, 6 cases of myasthenia gravis, 76 cases of spontaneous pneumothorax, 14 cases of chest wallandyor pleural tumor, 6 cases of empyema, and 4 cases of diaphragmatic disease. Blake drains functioned efficiently in 3 cases of re-operation for postoperative bleeding, 2 cases of adhesion therapy with drugs for persistent air leaks, and 1 case of re-operation forchylothorax. There were no cases of either complications or patient complaints of discomfort resulting from drain placement. The use ofBlake drains for general thoracic surgery is considered to be an acceptable option, and it is necessary to proceed with further investigationsof larger numbers of cases.� 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Small silastic drain; Blake drains; General thoracic surgery

1. Introduction

Chest tubes that are used following general thoracicsurgery must provide proper drainage of both airs and fluidsand must also reflect the information from the thoraciccavity. These requirements have traditionally been inducedwith the use of one or two 28–32Fr large bore plastic drains(conventional drains). However, these semi-rigid tubes cancause a patient discomfort and pain, potentially interferingwith the patient’s deep respiration and causing difficultyexpelling sputum andyor atelectasis. In addition, patientsoften complain of pain during the removal of the drain anddelayed wound healing at the drain insertion site. Recentlydeveloped silastic flexible drains (Blake drains, Ethicon,Inc., Somerville, NJ) are available in two sizes (19Fr and24Fr) and are expected to resolve such disadvantages posedby the use of conventional drains, and their utility asmediastinal drains used following cardiac surgery was firstreported in 2000 w1x. Subsequently, they have also beenused in several cases of thoracic surgery creating furtherdiscussion regarding their usefulness w2–6x. We have used19Fr Blake drains for the majority of 420 cases of generalthoracic surgery performed since 2005 and have obtainedgood results. We discuss whether the use of Blake drainsas chest tubes is an acceptable option.

*Corresponding author. Tel.: q81 859386737; fax: q81 859386730.E-mail address: hnaka@med.tottori-u.ac.jp (H. Nakamura).

2. Patients and methods

We began using Blake drains in November 2005, and byApril 2008, they had been used in a total of 420 cases.These cases in which Blake drains were used comprised 264males and 156 females, and the mean age was 59.8 years(range: 12–89 years). Only one Blake drain was placed foreach case. In each case, the drain was inserted through aninsertion point on the second or third intercostal anterioraxillary line and descended into the dorsal region via theapical portion of the lung to be placed on the diaphragm(Fig. 1). After confirming that there were no air leaks andthat the drainage was not bloody, purulent, or milky, thedrain was removed and the wound was closed with surgicaltape. Fig. 2a and b shows the conditions of a Blake drainduring placement and the conditions of the wound afterremoval. In order to examine the utility of Blake drains,we analyzed the diseases and surgical procedures for whichBlake drains were used, the chest tube duration, and thestatus of wound healing at the drainage site and examinedincidences of postoperative complications.

3. Results

The diseases for which Blake drains were used comprised181 cases of primary lung cancer, 44 cases of metastaticlung tumor, 57 cases of benign lung disease, 32 cases ofmediastinal tumor, 6 cases of myasthenia gravis, 76 casesof spontaneous pneumothorax and emphysematous lungdisease, 14 cases of chest wall andyor pleural tumor, 6

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Fig. 1. Method of insertion of Blake drains.

Fig. 2. Conditions of the 19Fr Blake drain during placement (a) and thewound (arrow) after removal (b).

Table 2Surgical procedures for which Blake drains were used

Panpleuro-pneumonectomy 1 (0)Lobectomy 135 (98)Segmentectomy 11 (9)Partial lung resectionybullectomy 206 (199)Resection of mediastinal tumor 36 (28)Extended thymo-thymectomy 6 (6)Chest wall andyor pleural resection 21 (15)Diaphragmatic resection 4 (4)

VATS, video-assisted thoracic surgery in parentheses.

Table 1Diseases for which Blake drains were used

Primary lung cancer 181Metastatic lung tumor 44Benign lung disease 57Mediastinal tumor 32Myasthenia gravis 6Pneumothoraxyempysematous lung disease 76Chest wall andyor pleural tumor 14Empyema 6Diaphragmatic disease 4

Fig. 3. Changes in the amount of drainage over time in a case of postoper-ative bleeding.

cases of empyema, and 4 cases of diaphragmatic disease(Table 1). Surgical procedures included 1 case of panleuro-pneumonectomy, 135 cases of lobectomy, 11 cases of seg-mentectomy, 206 cases of partial lung resection orbullectomy, 36 cases of mediastinal tumor resection, 6cases of extended thymo-thymectomy, 21 cases of chestwall andyor pleural resection, and 4 cases of diaphragmaticresection, and 61 of these cases underwent open thoracot-omy while the remaining 359 cases underwent video-assist-ed thoracic surgery (Table 2). The types of Blake drainsused included 19Fr drains (410 cases) and 24Fr drains(seven cases), and the two drains were used in combinationin three cases. The average chest tube duration by surgicalprocedure was 3.0 days for a panpleuro-pneumonectomy,2.7 days for a lobectomy, 1.5 days for a partial resectionor bullectomy, 2.5 days for a segmentectomy, 1.8 days for

mediastinal surgery, 2.7 days for pleural surgery, and1.3 days for diaphragmatic surgery.

Re-operation was required to treat postoperative bleedingin three cases (0.7%) in which 19Fr Blake drains were used.In our analysis of the amount of bleeding over time fromthe drains in these cases, the fluid was drained at a uniformrate in all the cases and re-operation was performed whenthe fluid level reached 500 ml at 1 h after surgery, 400 mlat 2 h after surgery, and 450 ml at 4 h after surgery,respectively (Fig. 3). The sites of bleeding included thetrocar insertion site in the chest wall in two cases and thedetached adhesion site in one case, and these were man-aged using 19Fr Blake drains again to obtain a good clinicalcourse. Advanced air leaks were observed in two cases inwhich a 19Fr Blake drain was used, and because of theoccurrence and progression of subcutaneous emphysema,the drain connector was removed on day 5 and day 6,respectively, after surgery and 5KE of OK-432 (group Astreptococcus pyogenes of human origin) was injecteddirectly into the thoracic cavity through the Blake drain.The air leaks immediately stopped and the subcutaneousemphysema also improved. After performing a chest X-rayand confirming that lung expansion was good, the drainwas removed on day 8 after surgery in both of the cases.Chylothorax developed on day 1 after surgery in one caseof mediastinal cyst originating from thoracic duct, but 600to 1400 ml of milky fluid was discharged daily and a chestX-ray confirmed that the patient had good lung expansion.On day 6 after surgery, re-operation was performed to clipthe thoracic duct under thoracoscope and the drain wasremoved on postoperative day 10.

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In the cases in which Blake drains were used, there wereno cases of complications or patient complaints of discom-fort resulting from drain placement. Moreover, all the casesin which Blake drains were used obtained good woundhealing at the drain insertion site over a single period.

4. Comment

The application of Blake drains for general thoracic sur-gery was first reported by Kejriwal and Newmann w2x in2005. In this report, 19Fr Blake drains were used for 37cases in which their safety and effectiveness were con-firmed. At approximately the same time, Stolz et al. w3xalso reported that they used 24Fr Blake drains in theanterior side when placing two thoracic drains and obtainedgood results, though they cited the low cost-effectivenessas a problem. Subsequently, Ishikura and Kimura w4x report-ed that they used 19Fr Blake drains and Icard et al. w5x andSaxena et al. w6x reported that they used 24Fr Blake drains,with each report confirming the effectiveness of theirrespective Blake drains, but these results were obtainedfrom small numbers of cases. We used Blake drains in 420cases of general thoracic surgery and confirmed that Blakedrains can be used for a variety of chest diseases andsurgical procedures. We would like to examine whetherBlake drains can be considered an acceptable standarddrain.

Traditionally, chest tubes have needed to combine thefunctions of both airs and fluids drainage, but the mainconcerns regarding Blake drains are twofold: whetherblood, milky fluid, and pus can be drained properly andwhether they can sufficiently respond to large amounts ofair leaks. Niinami et al. w7x compared the suction ability ofthe 19Fr Blake drain with that of the 28Fr conventionaldrain and found that while the suction is approximatelynine times higher for the conventional drain when used invitro, there was no significant difference in the amount ofdrainage over time in an in vivo animal experiment. This isbelieved to be due to the structure of the Blake drains,which have four open channels that are 30 cm in lengthfrom the pointed end, thus enabling a wide-ranging suctionability w5x. While it has been shown that there are noproblems in using Blake drains under normal clinical set-tings, there is still concern regarding its utility in the eventof bleeding. The primary role of the drain in the event ofbleeding is to enable the acquisition of proper information,and though three of our cases required re-operation forbleeding, each of these cases was treated satisfactorilyusing 19Fr drains. Clark et al. w8x have reported that whenthey inserted a 19Fr Blake drain on the right side and a24Fr conventional drain on the left side in a patientundergoing bilateral bullous resection and talc pleurodesis,life-threatening hypovolemic shock occurred on the rightside after the surgery. The cause was attributed to bleedingin the thoracic cavity that could not be drained due toocclusion of the drain that occurred as a result of throm-botic clots and talc particles. However, it is believed thatthe strongest level of suction in a Blake drain is generatedat the groove opening, which is an important portion w4x,and because this portion is located at the apical portion ofthe lung, the drain should be placed in a way that prevents

occlusion. In addition, in rare cases in which talc pleuro-desis is performed, it is preferable to use a 24Fr Blakedrain, which has a stronger suction ability than the 19FrBlake drain w5x. The effectiveness of 24Fr blake drains as amediastinal or pericardial drain used after cardiac surgeryhas been reported in many cases w9, 10x, including onereport from 2000 by Obey et al. w1x, and it is believed thatthey are effective for draining blood from the thoraciccavity as well. In reports that used 24Fr Blake drains toperform drainage of the thoracic cavity, including a ran-domized control trial of Blake drains and conventionaldrains, there is no significant difference between the twogroups in their drainage capacity w11–13x.

Postoperative chylothorax is a complication that can occuroften, but there have thus far been no reports indicatingthe effectiveness of Blake drains for treating such cases.Our report shows that Blake drains have sufficient function-ality for performing drainage. We believe that the discharg-ing of large amounts of turbid liquid is unproblematic. Interms of these concerns, Blake drains can also be used toperform drainage for empyema and pleuritis, but there isstill concern that the drain groove will become occludedwith fibrin masses and debris, and because the drain has asingle lumen, we believed that Blake drains are unsuitablewhen irrigation of the thoracic cavity is scheduled aftersurgery.

In cases in which a large amount of pulmonary fistulae ispresent, there is concern that the use of Blake drains willbe unable to provide sufficient air drainage, thus progress-ing subcutaneous emphysema. In order to sufficientlydischarge the air, the site of placement of the drain isimportant, and we have made adjustments to set thelateral groove opening of the drain at the apical portion ofthe lung. We believe that air drainage can thus be providedat levels similar to those provided when using a conven-tional drain. In addition, when pleural adhesions with drugsare required due to persistent air leaks, we believe that itis possible to address these conditions by means of directinjections through the drain as was done in three cases inthis study.

Blake drains have a level of functionality that is in no wayinferior to that of conventional drains, and they providethe advantages of slenderness and softness to reduce thelevels of discomfort experienced by patients during theplacement and removal of drains w14x. In addition, it isrecommended that each drain should be inserted from aseparate part to prevent wound infections such as SSI w15x,and it is believed that Blake drains address such concernsadequately while enabling good wound healing as seen inour results. In short, we believe that Blake drains provideenough benefits to be considered a standard drain. Inconclusion, we believe that the use of Blake drains forpostoperative drainage in the field of general thoracicsurgery is an acceptable option. However, there also arewith reason a lot of limitations in our single institutionalresults. We believe that it is worthwhile to proceed withfurther investigations of larger numbers of cases and planthe randomized comparative studies to determine theoptimal types of use and placement methods for specificdiseases and surgical procedures.

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