Do X-rays after chest tube removal change patient management? ☆ Bret Johnson a , Michele Rylander b , Alana L. Beres a, ⁎ a University of Texas Southwestern, Department of Surgery, Division of Pediatric General and Thoracic Surgery, Dallas, TX b Children's Health, Children's Medical Center Plano, Plano, TX abstract article info Article history: Received 9 January 2017 Accepted 23 January 2017 Available online xxxx Key words: Pneumothorax Pigtail Chest tube Tube thoracostomy X-ray Background: A link between childhood radiation and future cancer risks exists, and reduction of unnecessary radiation in childhood has been recommended. Pneumothoraces, pleural effusions, and many surgical procedures require placement of a chest tube/pigtail catheter. Traditional management is daily x-rays, with an x-ray after tube removal. Our hypothesis is the “post pull” x-ray rarely results in changing clinical management of the patient. Methods: With IRB approval, a 5-year retrospective chart review was performed. Inclusion criteria were chest tube or pigtail placed for any reason with complete records. Data collected were demographics, reason for and duration of placement, number of x-rays done prior to and after removal. Primary outcome was whether the “post pull” x-ray changed clinical management. Results: A total of 179 episodes were evaluated. Seventeen were excluded for incomplete data, or death/transfer of the patient with the tube in situ. Forty-nine tubes/pigtails were placed for pneumothorax, 48 for pleural effusion/ empyema, 9 for hemothorax, and 51 during operative procedure. A median of 5 x-rays was done post insertion. 99% of the patients (160/162) had a “post pull” x-ray performed after tube removal. In 9 cases the x-ray changed patient management. Conclusions: X-ray after chest tube/pigtail removal rarely changes patient management. We recommend considering imaging if there are clinical symptoms. Level of evidence: Prognosis study, level II (retrospective cohort) © 2017 Elsevier Inc. All rights reserved. The use of tube thoracostomy, whether in chest tube or pigtail cathe- ter format, is a common practice in modern-day pediatric surgery. From earliest descriptions of thoracostomy with Hippocrates, diagnoses that often necessitate chest tube placement today include pleural effusion or empyema, pneumothorax, traumatic chest injury, or operative placement during procedures such as lung resections [1]. Practical daily management of the tubes of pigtails is often diagnosis and provider dependent, and there is currently no standard of care, specifically related to timing and frequency of x-rays [2,3]. We know that x-rays are invaluable tools in not only potentially diag- nosing the need for chest tube placement, but also in supplementing clinical evaluation and determining readiness for tube discontinuation once the reason for placement has improved or resolved [2,4]. What continues to be debated, however, is the necessity of chest x-ray after discontinuation of the tube [2–6]. When questioning the timing and necessity of x-rays, particularly in the pediatric population, the ALARA (as low as reasonably achievable) principle must be considered [7]. This concept has helped to guide clinical practice for decades, suggesting that the lowest doses of radia- tion possible be utilized for diagnostic testing [7,8]. The correlation between radiation exposure during childhood and the development of cancer later in life has been clearly documented in the literature [9–12]. From even the smallest amount of radiation that is that emitted during routine dental x-rays, to more comprehensive radiology studies that are required during times of illness, children are potentially exposed to radiation multiple times during their time of growth and rapid cell turnover [10–12]. Two main issues with this include the following: First, children are known to be more susceptible to the carci- nogenic effects of ionizing radiation exposure than adults. Second, it is not only the exposure to the radiation that is concerning, but also the cumulative exposure over time. Consider these elements together and the child's risk of developing a radiation-induced cancer later in life is compounded exponentially [9–12]. Recent studies have proposed that omission of the post-pull chest x-ray after discontinuation of the chest tube or pigtail catheter in a patient that remains asymptomatic may be a reasonable change to implement into practice. Previous data have suggested that as little as 1%–4% of patients evaluated required intervention following chest tube discontinuation [3,4,6]. Given the varied practice patterns for even the timing and frequency of x-ray evaluations, our goal was to evaluate if the x-ray obtained after chest drain removal resulted in a significant amount of practice change. Our hypothesis is that in asymptomatic Journal of Pediatric Surgery xxx (2017) xxx–xxx ☆ Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author at: University of Texas Southwestern, Department of Surgery, 1935 Medical District Drive, D-2000, Dallas, TX 75235. E-mail address: alana.beres@mail.mcgill.ca (A.L. Beres). http://dx.doi.org/10.1016/j.jpedsurg.2017.01.047 0022-3468/© 2017 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg Please cite this article as: Johnson B, et al, Do X-rays after chest tube removal change patient management?, J Pediatr Surg (2017), http:// dx.doi.org/10.1016/j.jpedsurg.2017.01.047