Comment:
In this study, the aim was to examine the effect of application of a standardized treatment protocolearly on after the Fontan procedure, on prolonged drainage and LOHS. Our main findings included that the use of a standardized treatment protocol reduced the total drainage amount, duration of pleural drainage, prolonged drainage and LOHS after the Fontan procedure.
Various protocols that were previously used to reduce total drainage and the duration of pleural drainage have been reported in the literature. First, Cava and colleagues published their protocols to reduce pleural drainage. After the initiation of the protocol they reported that the duration of pleural drainage and LOHS shortened in the protocol group (4). Sunstrom et al, published another protocol called PORTLAND protocol which includes peripheral vasodilation, oxygen, fluid restriction, a modifiedsurgical technique, low-fat diet, anticoagulation anddiuretic therapywithout ventilation. In this protocol, routine fenestration was recommended in addition to the medical treatment. They alsoreported in their study that, the LOHS and the total drainagewas shortened (7). Pike et al, published their own postoperative medical management strategies under the name of Modified Wisconsin protocol. This protocol was a modified version of the protocol reported by Cava et al. In this study, it was reported that theduration of pleural drainage, prolonged drainage and LOHS were decreased (6). Although operative data (CPB and ACC times) were not considered, all these studies reported that a standardized treatment protocol improved the outcomes. In our study there were no difference in terms of preoperative and intraoperative variables and performing fenestration. The total drainage and LOHS were reduced by application of a standardized treatment protocol. Total drainage (111 vs 85 ml / kg), LOHS (15 vs 12 days), duration of pleural drainage (10 vs 7.8 days) and incidence of prolonged drainage (35 vs 23) were all lower in the protocol group.
There has been no consensus regarding the use of a fenestrated Fontan and the decision of fenestration has been associated with institutional experience and personal preferences. Regardless of the anatomical subtype, we adopted the non-fenestrated EC Fontan policy and preferred to fenestrate only the high-risk patients (pathologies withatrioventricular valve regurgitation and those with high PVR, high end diastolic pressure and delayed patients). A standardized treatment protocol together with selective use of fenestration did provide a hospital stay below average and with the marking method used during surgery, transcatheter fenestration opening was possible without a need for surgery.
In a study where parameters affecting drainage after EC Fontan were investigated, Gupta et al. showed that preoperative low oxygen saturation level, long CPB duration, small conduit size and postoperative infection were risk factors for prolonged drainage (8). In their study, Salvin et al. reported that age, PVR, preoperative CVP, postoperative CVP, postoperative left atrial pressure, CPB duration, high volume resuscitation and high inotropic score were associated with prolonged recovery (9). There are publications reporting that right ventricular morphology, HLHS and not to perform fanestration related to prolonged drainage and prolonged LOHS (10,11). It was thought that early extubation was associated with shorter drainage time and hospital stay (12). There were also articles reporting that IEC Fontan procedure was related with shorter drainage period than the EC Fontan procedure (13). In our study, absence of a standardized treatment protocol wasdetermined as a risk factor for prolonged drainage.
The findings in this study were comparable to other Fontan management protocols (4-6). Our study was conducted in aperiod of 3 years. The study was conducted between two demographically similar groups which were homogeneous in terms of hemodynamic and peroperative parameters. These features make the study more valuable. The routine use of the protocol, eliminated the confusions about drain removal. The shortening of the stay of the drain caused concerns of increase in rate of re-hospitalization due to pleural effusions during follow-ups. However, there was no difference between groups regarding chest tube reinsertion. We were not routinely using nasal oxygen, sildenafil, low-fat diet until 6 weeks after the discharge and fluid restriction, but only in selected patients. We are using now routinely. Another innovation in our medical management strategy was to increase the doses of furosemide used according to protocol. These reduced the incidence of pleural effusions and LOHS after the Fontan procedure.