Guidelines for routine assessment of cardiologic surgical risk: electrocardiogram

Cardiac complications are the main cause of perioperative mortality. A preoperative electrocardiogram and cardiologist's consultation are usually performed to get information about cardiac state of patients undergoing surgery and to prevent complications. In their study the Authors applied to 1715 patients undergoing surgery an evaluation schedule for the cardiac surgical risk, including an ECG as first-level test, performed systematically on the whole sample. The aim was to assess predictive value of this preoperative examination to verify its efficacy as routine test. Basing on results achieved, electrocardiogram is not routinely indicated before noncardiac elective surgery, but it should be requested for the patients having high risk of cardiac complications at an accurate clinical-anamnestic examination. Therefore, clinical judgement, that is the first level of any preoperative evaluation, should be the basis for ordering an ECG to be considered a second-level test.     

Functional studies in blunt thoracic trauma with special reference to perfusion and ventilation scintigraphy

In 10 patients we carried out a routine chest X-ray examination together with an arterial blood gas analysis, spirometry and a combined pulmonary perfusion/ventilation scintigram. Scintigraphy was shown to be the most sensitive method in the detection of impaired post-traumatic pulmonary function. Since it is a time-consuming method requiring sophisticated equipment it is of limited value for routine examinations. Spirometric results during the immediate post-traumatic period are difficult to interpret as a result of severe chest pains which may inhibit respiratory movements. Arterial blood gas analysis which is easily performed is of high value in accessing the actual pulmonary function.     

Is routine chest X-ray following mediastinal drain removal after cardiac surgery useful?

Objective: Mediastinal and pleural drains are routinely employed following open-heart surgery to prevent accumulation of blood and fluids in the mediastinum or the pleural cavities. Chest radiographs are obtained after removal of these drains to search for a pneumothorax. We hypothesised that clinical signs and symptoms are sensitive indicators of the presence of significant pneumothorax and routine use of radiographs in these patients is unnecessary. Methods: A prospective study of 151 consecutive patients undergoing various cardiac surgical procedures over a 10-week period was undertaken. Chest X-rays were performed in all patients within 4h of drain removal. Patients were clinically monitored for development of any respiratory difficulties and the X-rays were evaluated for presence of a pneumothorax or any other abnormality necessitating intervention. The cost of a portable chest X-ray was calculated by taking into consideration the radiographer's time and the cost of an X-ray film. Results: There were 113 males and 38 females with a mean age of 67.5 years. Fourteen patients (9%) had obstructive airway disease. The left and right pleurae were opened in 62% and 11% of patients respectively and a chest drain was inserted in all of them intraoperatively. Three patients (2%) developed pneumothorax following drain removal. Two of these patients had clinical signs and symptoms, which would have warranted a chest X-ray. One patient had a moderate pneumothorax but was not clinically compromised. Two patients needed chest drain reinsertion that was subsequently removed after 3 and 4 days. The third patient was monitored clinically and the pneumothorax resolved spontaneously on subsequent chest X-ray. In the remaining 148 patients, postdrain removal chest X-ray did not provide any additional information to alter the management. The cost saving of omitting an additional chest X-ray was calculated to be about pound10,000 per year. Conclusions: Incidence of pneumothorax following mediastinal drain removal is very low. Clinical signs and symptoms almost always identify those few patients requiring intervention and the decision to obtain an X-ray could be based on clinical judgement alone. In addition, this approach may result in cost savings without compromising patient safety.     

The use of chest computed tomography versus chest X-ray in patients with major blunt trauma

INTRODUCTION: Computed tomography (CT) scans are often used in the evaluation of patients with blunt trauma. This study identifies the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a standard chest X-ray in patients sustaining blunt trauma to the chest. METHODS: A 2-year retrospective survey of 141 patients who attended a Level 1 trauma centre for blunt trauma and had a chest CT scan and a chest X-ray as part of an initial assessment was undertaken. Data extracted from the medical record included vital signs, laboratory findings, interventions and the type and severity of injury. RESULTS: The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR=6.73, 95% CI=2.56, 17.70, p<0.001), reduced air-entry (OR=4.48, 95% CI=1.33, 15.02, p=0.015) and/or abnormal respiratory effort (OR=4.05, 95% CI=1.28, 12.66, p=0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. CONCLUSION: In alert patients without evidence of chest wall tenderness, reduced air-entry or abnormal respiratory effort, selective use of CT chest scanning as a screening tool could be adopted. This is supported by the fact that most chest injuries can be treated with simple observation. Intubated patients, in most instances, should receive a routine CT chest scan in their first assessment.     

Value of preoperative screening studies

In order to develop a sensitive and economically reasonable preoperative screening program capable of identifying perioperative risk factors, we performed a prospective study on patients scheduled for elective urological surgery. According to age, 379 patients were assigned to six groups. After the history and physical examination had been completed the attending anesthesiologist classified the patient's anesthetic risk according to ASA criteria. Furthermore, based on his clinical impression he ordered an individual set of screening parameters (laboratory tests, X-ray films, electrocardiography (ECG), and other appropriate diagnostic procedures) to be done. This "individual" screening and its results were compared with the results of the larger "routine" preoperative screening program performed independently of the study for all patients. All cases were then followed up in order to document perioperative complications. We were thus, able to recognize risk-identifying screening parameters resp. pathological findings missed by the "individual" screening. Laboratory tests from the nonselective "routine" screening yielded pathological results in a relatively high percentage of 31.4% of cases. ECG alterations or chest X-ray findings relevant to the patient's anesthetic management were present in 26.1% resp. 13.6%. Observations missed by the "individual" screening, though important for the prevention of perioperative complications, were pathological ECGs in only 1.9% of all cases. An influence of patient age on the frequency of pathological screening results and perioperative complications could be shown. Laboratory tests, chest X-rays and additional diagnostic procedures should be restricted to patients with pathological results or physiological examination. Our results underline once more the importance of a carefully taken history, a meticulous physical examination and the preoperative performance of an ECG for patients of every age scheduled for anesthesia and surgery.     

A pilot study of zafirlukast as an anti-inflammatory agent in the treatment of adults with cystic fibrosis.

BACKGROUND: Persistent endobronchial inflammation is in part responsible for the attrition of lung function seen in cystic fibrosis. Leukotrienes act as pro-inflammatory mediators. The aim of this study was to assess the efficacy of the leukotriene receptor antagonist zafirlukast as a potential anti-inflammatory agent in the treatment of adult patients with cystic fibrosis. METHODS: Clinically stable patients were enrolled in the study if they had no history or clinical evidence of asthma, bronchial hyper-reactivity, or aspergillosis. They were randomised to receive zafirlukast 20 mg twice daily with all routine treatment for four months or routine treatment alone in an open cross-over design. Primary endpoints were changes in respiratory function tests and a modified NIH clinical score. RESULTS: Thirty patients were enrolled and 25 completed. There was a significant improvement in the modified NIH clinical score but no significant increase in respiratory function with zafirlukast. CONCLUSIONS: Patients receiving a leukotriene receptor antagonist in addition to routine treatments showed significant improvement in a clinical score which is a composite of clinical wellbeing, chest radiograph appearance, and physical examination. Respiratory function showed a non-significant trend towards improvement with treatment. Zafirlukast may benefit patients with CF. An adequately powered study is justified on the basis of these results.     

Routine chest X-ray is not required after a low-risk central venous cannulation

Background: Knowledge of the radiographic catheter tip position after central venous cannulation is normally not required for short-term catheter use. Detection of a possible iatrogenic pneumothorax may nevertheless justify routine post-procedure chest X-ray. Our aim was to design a clinical decision rule to select patients for radiographic evaluation after central venous cannulation.
Methods: A total of 2230 catheterizations performed using external jugular, internal jugular or subclavian venous approaches during a 4-year period were included consecutively. Information on patient data and corresponding procedures was recorded prospectively. A post-procedure chest X-ray was obtained after each cannulation.
Results: Thirteen cases (0.58%) of cannulation-associated pneumothorax were identified. The risk of pneumothorax after a technically difficult (1.8%) or subclavian (1.6%) cannulation was significantly higher than after cannulation not considered as difficult (0.37%) or performed using other routes (0.33%). Clinical signs of pneumothorax within 8 h of cannulation were found in all seven patients with pneumothorax requiring specific treatment. A new clinical decision rule for radiographic evaluation after central venous cannulation based on the results of the present study shows that 48% of the post-procedure chest X-rays performed in our patients were clinically redundant.
Conclusion: Clinical symptoms were reported in all patients with pneumothorax requiring specific treatment. Approximately half of the post-procedure chest X-ray controls could be avoided using the proposed clinical decision rule to select patients for radiographic evaluation after central venous cannulation. A large prospective multi-centre study should be carried out to further evaluate this decision rule.     

Is preoperative systematic chest x-ray useful in general surgery? A multicenter prospective study of 3959 patients. ACAPEM. Association des Chirurgiens de l'Assistance Publique pour les Evaluations Médicales]

In order to define which patients may not require a routine preoperative chest X-ray, a prospective multicenter study was carried out. It included 3,959 consecutive fifteen, or more, year-old patients, free from any cancer, scheduled for a general or gastrointestinal surgical procedure other than thoracotomy, and had a plain chest X-ray beforehand. This investigation was prescribed before surgery, either by the surgeon or the anaesthetist. Patients were classified according to selected risk factors: age, smoking, emergency surgery, a past history of lung, heart or vascular disease, abnormal clinical findings related to the cardiovascular and respiratory systems, and a previous chest film made less than one year before. There were 2,092 patients in Group I (no risk factors), 916 in group II (one risk factor), 645 in Group III (two risk factors), and 276 in group IV (three risk factors). Three endpoints were selected: a modification of operative schedule or anaesthetic technique, a change in surgical procedure, and the diagnosis of postoperative complications. A rate of 23.2% of preoperative chest films were considered to be abnormal. This rate increased with age and the number of risk factors: 6.2% in Group I and 72.5% in Group IV. Surgical and anaesthetic procedures were modified as a result of the chest X-ray in only 0.5% of patients: 0.1% in Group I, 0.3% in Group II, 1.2% in Group III and 1.4% in Group IV. When pulmonary or cardiac complications did occur after the surgery, the preoperative chest film was of no help for making this diagnosis in more than 50% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical predictors for the selective use of chest radiographs in pediatric blunt trauma evaluations

BACKGROUND: Chest radiographs continue to be a routine part of the evaluation of children sustaining blunt trauma. This study sought to determine those clinical markers associated with an abnormal chest radiograph in nonintubated, pediatric, blunt trauma victims. METHODS: A retrospective case-control study was performed for severely injured pediatric trauma patients presenting to our emergency department between January 1, 1996, and December 31, 1997. Abnormal chest radiographs were identified through the trauma registry and four controls were matched to each case. Radiographs were reevaluated by our study radiologist. Variables associated with an abnormal chest radiograph were grouped to develop a set of clinical markers that could predict an abnormal chest radiograph with a high degree of sensitivity. RESULTS: An initial chest radiograph was obtained in 457 of 587 trauma patients. Thirty study patients with an abnormal radiograph that met inclusion criteria were analyzed with 133 controls. The presence of either an abnormal respiratory rate for age, chest tenderness, or back abrasions had a sensitivity of 1.0 (95% confidence interval, 0.86-1.0) and a specificity of 0.38 (95% confidence interval, 0.30-0.47). CONCLUSION: In pediatric trauma patients, the presence of chest tenderness, back abrasions, or an abnormal respiratory rate identified all abnormal chest radiographs.     

Prospective evaluation of the sensitivity of physical examination in chest trauma

BACKGROUND: Chest radiographs are routine for patients presenting with blunt and penetrating chest trauma. The accuracy of physical examination in the diagnosis of hemopneumothorax in these patients is unclear. A prospective study was performed to define the utility of routine portable chest radiographs in 676 trauma patients. METHODS: Over 19 months (January 2000-July 2001), 676 patients who presented with penetrating or blunt chest trauma were interviewed and examined for signs and symptoms of hemopneumothorax. The incidence of chest pain or tenderness and tachypnea was noted and both lung fields were auscultated. A portable chest radiograph was then performed on all the patients. RESULTS: All the patients were hemodynamically stable. Five hundred twenty-three patients sustained blunt trauma, with seven hemopneumothoraces (1.3%). The negative predictive values of auscultation, pain or tenderness, and tachypnea were 99& to 100%. One hundred fifty-three patients sustained penetrating chest trauma. Of these injuries, 68 were gunshot wounds and 85 were stab wounds. Twenty-four (16%) of these patients had hemopneumothoraces. The sensitivities of auscultation, pain or tenderness, and tachypnea were 50%, 25%, and 32%, respectively. The negative predictive values of these tests were < 91%. CONCLUSION: Blunt chest trauma patients who are hemodynamically stable with a normal physical examination do not require a routine chest radiograph. In contrast, all victims of penetrating trauma require chest radiographs because many will have hemopneumothorax in the absence of clinical findings.     

Comparison of postoperative cardiopulmonary examinations and chest radiographs to detect pulmonary complications after adult tracheotomy.

OBJECTIVE: To prospectively evaluate the effectiveness of clinical cardiopulmonary examination compared with that of chest radiography in detecting postoperative pulmonary complications after tracheotomy in adults. METHODS: One hundred consecutive patients undergoing tracheotomy were evaluated. Pulmonary complications were recorded, and the effectiveness of the physical examination was compared with that of the chest x-ray in detecting these complications. Patient age, sex, diagnosis, urgency of the procedure, and anesthetic technique were evaluated to determine any relationship to postoperative complications. RESULTS: Of the 100 patients, 87 patients underwent postoperative chest radiography, and all patients had postoperative cardiopulmonary examinations. One patient (1%) had a bilateral pneumothorax, which was detected clinically and confirmed by a chest radiograph. Five patients had postoperative pulmonary edema confirmed by clinical examination and radiography. Additional minor complications were noted, including minor bleeding and stomal infection, for an overall complication rate of 13%. CONCLUSIONS: All postoperative pulmonary complications were detected by physical examination. Therefore routine postoperative chest radiographs in uncomplicated tracheotomies are not necessary if a thorough postoperative cardiopulmonary examination is performed. Cost analysis reveals a savings of approximately $19,000 with the proposed criteria for postoperative chest x-ray.     

A case of thymic carcinoid with multiple endocrine neoplasm (MEN)-type I]

We presented a case of thymic carcinoid with MEN type I. A 43-year-old woman who followed at MEN type I for 4 years was pointed out an abnormal shadow by chest X-ray. Chest CT levealed the presence of two anterior mediastinal tumors. Extended total thymectomy was performed through the median sternotomy. There were 3 tumors in thymus. Histological examination revealed three tumors in the thymus and all of the tumor were diagnosed carcinoid. Our experience suggests that CT or MRI of the chest should be considered as part of clinical screening in patients with MEN type I.     

Clinical rib fractures: are follow-up chest X-rays a waste of resources?

Rib fractures (RFs) are estimated to be present in 10 per cent of all traumatic injuries. However, up to 50 per cent of all fractures go undetected on the screening chest X-ray (CXR). The purpose of this study was to identify the incidence of clinical (CRFs) and objective rib fractures (ORFs) as well as to examine the utility of the routine follow-up CXR with regard to patient recovery and healthcare cost. We identified patients sustaining RF in addition to other traumatic injuries with an Injury Severity Score (ISS) < or = 15 and RF as the primary pathology. Five hundred fifty-two patients sustained blunt thoracic trauma with resultant RF. Two hundred nine patients had RFs and an ISS < or = 15. The average ISS was 8. Follow-up films illustrated that 93 per cent of CRFs had resolution of any pathology, 4 per cent had persistent X-ray findings, and 4 per cent were lost to follow-up. Ultimately 93 per cent of patients with CRF were able to resume daily activities without disability and 3 per cent incurred lifestyle changes at home or work, which was significantly better than those with ORFs (P < 0.05). Follow-up films produced no change in clinical management and cost approximately $2000/year. The prognosis for CRFs is excellent if treatment consists of appropriate pain management and pulmonary rehabilitation. We do not advocate routine follow-up CXRs in addition to physical examination for the evaluation of CRFs unless clinical deterioration is evident.     

Follow-up after treatment of primary breast cancer

This study evaluates the usefulness of routine follow-up of breast cancer patients. In all, 416 patients who were treated with curative intent for breast cancer were followed according to a fixed follow-up schedule for a minimum of 2.5 years and a maximum of 13.5 years (mean about 5 years). During the 4533 routine out-patient visits, 4116 chest radiographs, 3889 pelvic radiographs and about 17,000 laboratory tests were carried out routinely. In the follow-up period, 148 patients were found to have distant recurrence of whom 34 (23 per cent) had asymptomatic metastases and 114 symptomatic metastases. Of the 8005 routinely performed radiographs, 24 (0.3 per cent) revealed asymptomatic metastases, and the 17,000 laboratory tests led to the discovery of six asymptomatic bone and four asymptomatic liver recurrences. Screening for metastases did not result in a reduction of the lead time to the diagnosis of asymptomatic metastases; the disease-free interval was equal in both symptomatic and asymptomatic patients. Of the 46 locoregional recurrences 42 were found by physical examination during a routine follow-up visit and 37 had not been noticed by the patient. Seventeen second primary breast cancers were diagnosed, six of which were in stage I (less than 2 cm). Mammography was not a part of the routine follow-up scheme. It is concluded that routine follow-up of breast cancer patients by history and physical examination is sufficient to detect local recurrence and a second primary tumour as well as giving the opportunity to track signs and symptoms of distant recurrence at an early stage. Performing annual or biannual mammography is advisable, but the use of other costly routine investigations in the follow-up is not justifiable, as no therapeutic advantages can be expected.     

Sarcoidosis Presenting as Cold Thyroid Nodules: Report of Two Cases

Sarcoidosis is a systemic disease characterized by noncaseating granulomas. Thyroid involvement is rare in sarcoidosis. In this paper, two sarcoidosis patients who demonstrated cold thyroid nodules are presented. A 42-year-old woman presented with multinodular goiter and was diagnosed as having sarcoidosis when noncaseating granulomas were observed during the pathological examination of the thyroidectomy specimen. Enlarged mediastinal lymph nodes were observed in the routine preoperative chest X-ray in another 53-year-old woman, while she was being prepared to undergo a thyroidectomy. The pathological examination of the thyroid specimens showed noncaseating granulomas in both patients, and the diagnosis was confirmed by either hepatic biopsy or chest X-ray findings. In conclusion, thyroid involvement should be suspected in sarcoidosis patients who present with cold nodules in the thyroid. Furthermore, if noncaseating granulomas are observed in thyroid specimens after a thyroidectomy in an otherwise healthy person, the patient should be evaluated further for sarcoidosis.     

What is the role of chest X-ray in the initial assessment of stable trauma patients?

BACKGROUND: The Advanced Trauma Life Support course advocates the liberal use of chest X-ray (CXR) during the initial evaluation of trauma patients. We reviewed CXR performed in the trauma resuscitation room (TR) to determine its usefulness. METHODS: A retrospective, registry-based review was conducted and included 1,000 consecutive trauma patients who underwent CXR in the TR at a Level I trauma center during a 7-month period. RESULTS: Patients receiving CXR comprised 91.5% of all patients evaluated in the TR during the study period. CXR followed by chest computed tomography (CCT) was performed in 820 (82.0%) patients. Subsequent CCT identified missed findings in 235 (35.6%) of the 660 patients with an initial negative CXR who went on to receive CCT. CXR alone was performed in 127 (26.1%) of the 487 patients who were stable, not intubated, and had a normal chest physical examination (CPE). Seven patients (5.5%) in this group had potentially significant findings but none required intervention beyond physiotherapy or antibiotics. Three hundred and sixty (73.9%) of the 487 patients who were hemodynamically stable with a normal CPE underwent both CXR and CCT. Fifty-four patients (15%) in this group had findings of significance, and two (0.6%) required intervention. One patient received bilateral chest tubes for large pre-existing pleural effusions found on CXR and CCT; another patient undergoing general anesthesia required a chest tube for a pneumothorax found only on CCT. CONCLUSION: In stable trauma patients with a normal CPE, CXR appears to be unnecessary in their initial evaluation. CXR should be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination, and should be limited to use only for clear clinical indications.     

Incremental value of pocket-sized imaging device for bedside diagnosis of unilateral pleural effusions and ultrasound-guided thoracentesis

OBJECTIVES The present study aimed to assess the additional value of a pocket-sized imaging device (PSID) as an adjunct to plain chest X-rays in the diagnosis of pleural effusion (PE), mainly for those requiring pleural thoracentesis. METHODS We performed a thoracic ultrasound examination using a PSID in 73 patients with an abnormal chest X-ray diagnostic for unilateral PE. Abundant PE was defined as an interpleural distance between the diaphragm and visceral pleura (VP) of ≥30?mm at the apex of the 50?mm bisector line of the costodiaphragmatic recess at end expiration. RESULTS According to PSID ultrasound evaluation, abundant PE was present in 46 patients (63%), while 27 (37%) patients showed the presence of mild PE or absence of PE. Thoracentesis was performed successfully and without procedure-induced complications in all 46 patients with abundant PE. Using the above-mentioned method, we obtained a high diagnostic accuracy (area under the curve?=?0.99) and excellent sensitivity and specificity of 91.7 and 99.9%, respectively, to predict a PE?>1000?ml, when VP was >6.3?cm. CONCLUSIONS PSID is a useful tool that may integrate and complete the physical examination, also providing additional information to chest X-ray in the clinical management of patients with suspected PE. PSID evaluation can also increase the effectiveness and safety of thoracentesis.     

Routine chest X-ray after percutaneous tracheostomy is unnecessary

Percutaneous tracheostomy (PT) is an increasingly common procedure in the management of critically ill patients. Current practice for both open and percutaneous tracheostomies is a post-procedure chest X-ray to rule out potentially life-threatening complications such as a pneumothorax or tube malposition. Our study evaluated the utility of chest X-ray after PT. A retrospective chart review was conducted for patients undergoing PT at Kern Medical Center between January 1999 and December 2003. Charts were reviewed for age, sex, and clinical outcome as well as the radiologist's interpretation of the postprocedure chest X-ray. A total of 73 procedures were completed in 47 men and 26 women. The majority of the tracheostomies were in trauma patients who needed prolonged ventilatory support. There were no complications identified on postprocedure chest X-ray. A single patient was converted to an open procedure secondary to bleeding. We conclude that routine chest X-ray after PT is unnecessary.     

Volumetry of pleural effusion in multi-morbidity, postoperative patients of a surgical intensive care unit. Comparison of ultrasound diagnosis and thoracic bedside image

Aim of this study was to evaluate the importance of chest ultrasound and chest x-ray for the indication of thoracic drainage of pleural effusions in patients of an operative intensive care unit. Between December 1996 and June 1997 21 patients were included in a prospective trial in the operative intensive care unit. 26 thoracic drainages were used to drain pleural effusions. In all patients chest radiography in supine position and chest ultrasound were performed to assess the need of pleural drainage. Pleural fluid measured radiologically was categorized into 3 groups: pleural fluid less than 500 ml, 500 to 1,000 ml or more than 1,000 ml. The amount of the pleural effusion was sonographically determined by a standardized formula. After complete drainage of the pleural space the real volume of the fluid was measured and compared with the estimated value. The real amount of the fluid was correctly determined by chest radiographs in 16 cases (62%) and by chest ultrasound in 18 patients (69%). Pleural effusions less than 600 ml sonographically correlated much better with the real amount of the fluid than pleural effusions above 600 ml. In 8 cases (31%) ultrasound provided an additional information for correct indication of drainage. Considering both x-ray of the chest in supine position and chest ultrasound the correct indication to drain the pleural effusion was achieved in 25 cases (96%). In this prospective trial we compared chest ultrasound and chest radiography and demonstrated that ultrasound is more suitable to determine the amount of pleural effusions than radiography. In case of clinical and radiological suspicion on pleural effusion demanding for drainage a chest ultrasound should be performed to avoid underestimation of pleural fluid.     

Routine postoperative chest x-ray following laparoscopic nephrectomy.

PURPOSE: To determine whether a routine postoperative chest x-ray is required following uneventful laparoscopic nephrectomy to rule out pneumothorax. METHODS: From June 1999 to May 2003, 308 laparoscopic nephrectomy cases were performed by 5 different surgeons. This consisted of 121 radical nephrectomies, 106 donor nephrectomies, 29 simple nephrectomies, 29 partial nephrectomies, and 23 nephroureterectomies. Of the 308 procedures, 186 postoperative chest x-ray s were obtained in the recovery room: 183 routinely and 3 for known intraoperative diaphragmatic injuries. Routine chest x-rays were not obtained in 122 cases due to the individual surgeon's preference. Of these 122 patients, 15 underwent chest x-ray performed while hospitalized secondary to pulmonary issues or fever. RESULTS: Of the 308 cases, 4 pneumothoraces were identified on chest x-ray. Three were identified in the patients who had intraoperative identification of diaphragmatic injury. The fourth pneumothorax was identified in a patient who did not have a routine postoperative chest x-ray but did have a chest x-ray obtained due to postoperative shoulder pain. The pneumothorax in this patient resolved spontaneously. No incidental findings existed of pneumothorax in any patient who underwent routine postoperative chest x-ray. CONCLUSION: In our series, a pneumothorax was identified either intraoperatively or based on postoperative clinical findings. None of the 183 routine postoperative chest x-rays changed patient management. Routine postoperative chest x-ray is not necessary in uncomplicated laparoscopic nephrectomy.