The Validation of a No-Drain Policy After Thoracoscopic Major Lung Resection

From data to prediction: Digital chest drain insights into postoperative recovery after lung cancer surgery

OBJECTIVE

Prolonged air leak is one of the major complications following lung cancer surgery and objectively measured digital drainage data have been investigated as predictive factors. With this scoping review, we aim to provide a comprehensive overview of risk factors, derived from digital drainage data, for predicting postoperative (drainage) course after pulmonary resection in patients with lung cancer.

METHODS

MEDLINE and EMBASE were systematically searched for studies that investigated digital drainage data after lung cancer surgery. Systematic reviews, editorials, commentaries, and reports in languages other than English were excluded. Data on general study information, characteristics of the procedures, digital drainage parameters, and clinical postoperative outcomes were extracted.

RESULTS

Twenty-three studies were included, comprising 3,649 patients. Four different digital drainage systems were used. Maximum air flow exceeding 100-200 ml/min (5 studies), variable air leak patterns (3 studies), and less negative intrapleural/differential pressure (7 studies) were associated with prolonged air leak. A mean air flow of <50 ml/min was associated with spontaneous air leak resolution (1 study). However, chest tube management was heterogeneous, with different suction levels and chest tube removal criteria being applied.

CONCLUSIONS

Mean and maximum air flow, air leak patterns, and intrapleural/differential pressure derived from digital drainage data can be considered as possible predictors for postoperative prolonged air leak after lung cancer surgery. However, definitive evidence on the use of these predictive factors in a future risk prediction model could not be provided, due to a lack of homogeneity in the chest tube strategies used in the reviewed studies.

Long-term outcomes of drainless anatomical lung resection surgery for pulmonary malignancies

OBJECTIVE

Drainless minimally invasive anatomical lung resection surgery for pulmonary malignancies is safe and feasible in terms of early postoperative outcomes. However, the quality of surgery in the long term remains uncertain. This study aimed to investigate the perioperative outcomes, 3-year overall, and disease-free survival rates of patients who underwent minimally invasive anatomical lung resection surgery with the drainless technique for pulmonary malignancies.

METHODS

Fifty-eight patients who underwent drainless minimally invasive anatomical lung resection surgery for pulmonary malignancies (36 -lobectomy; 22 -segmentectomy) between November 2017 and June 2022 by a single surgeon were enrolled. Patients' characteristics and perioperative, early postoperative, and long-term data were collected. The lymph node dissection stations and number, resection margin, 3-year overall and disease-free survival rates were assessed.

RESULTS

The median age was 64 years. Forty-four patients were females (76%) and forty-seven patients were non-smokers (81%). The median five-factor modified frailty index was 1. Most patients had primary lung cancer; four (7%), 43 (74%), seven (12%), and three (5%) had stage 0, I, II, and III, respectively. The median lymph node dissection stations was four, and the number was 17. The resection margin was free in 98% of the cases. The 3-year overall survival rate was 98.3% in all patients, and 97.2% and 100% in the lobectomy and segmentectomy subgroups, respectively. The 3-year disease-free survival rate was 85.3% in all patients and 80.5% and 92.9% in the lobectomy and segmentectomy subgroups, respectively.

CONCLUSION

The drainless technique is safe and feasible for minimally invasive anatomical lung resection surgery for pulmonary malignancies in terms of early postoperative and long-term outcomes. However, further randomized controlled studies are warranted.

The clinical features and operation experience of multilobar involved congenital lung malformation: A retrospective cohort study

BACKGROUND

Congenital lung malformation (CLM) is usually characterized by single-lobe involvement and multilobe involvement is uncommon. There is a lack of experience in the clinical features and surgical treatment of unilateral multilobar CLM. Therefore, this study aims to summarize the clinical characteristics and evaluate the safety and feasibility of thoracoscopic lung sparing resection in the treatment of unilateral multilobar CLM.

METHODS

A retrospective study was conducted on 34 patients with unilateral multilobar CLM, and 34 unilobar patients were randomly selected as the control group in West China Hospital of Sichuan University from 2014.1 to 2021.1. Clinical, operation and follow-up outcomes were compared between the two groups.

RESULTS

Twelve (35.2%) patients developed preoperative symptoms in the multilobar group more than 4(11.7%) the unilobar group (p = 0.02), the main preoperative symptom was infection; The multilobar group and unilobar group showed significant differences in mean intraoperative blood loss (13.3 mL vs. 7.5 mL; p = 0.02) and mean surgical time (95.6 min vs. 47.5 min; p = 0.037). The median length of postoperative hospital stay and the median chest tube placement time in the multilobar group were significantly longer (5 d vs.3 d, p = 0.045; 2 d vs.1 d, p = 0.031). There were one (2.9%) patient in unilobar group and 4(11.7%) patients in multilobar group developed complications postoperatively, which is no significant differences between the two groups(p = 0.16). No complications such as thoracic deformity, mediastinal deviation, scoliosis or recurrence were observed in either group at follow-up.

CONCLUSIONS

Unilateral multilobar CLM cases are more susceptible to develop symptoms than unilobar cases. Thoracoscopic lung sparing resection in the treatment of unilateral multilobar CLM has high safety and can effectively avoid serious complications of unilateral multiple lobectomy or pneumonectomy.

Effectiveness of Stitch With Pledget to Prevent Prolonged Air Leak in Thoracoscopic Lung Resection

INTRODUCTION

We previously demonstrated the usefulness of combining stitching with covering to seal alveolar air leaks in an animal model. This study aimed to clarify the effectiveness and feasibility of this sealing method in the clinical setting.

METHODS

Data of 493 patients who underwent thoracoscopic anatomical resection between 2013 and 2020 for lung cancer were retrospectively reviewed. Prolonged air leak was defined as chest drain placement lasting 5 d or longer due to air leak. Until July 2017 (early study period), we covered air leaks using mesh. However, for sealing (late study period), we additionally stitched leaks with pledget in patients at high risk of prolonged air leak. The pneumostasis procedure, intraoperative confirmation test of pneumostasis, and chest tube management were uniform during both periods.

RESULTS

The incidence of prolonged air leak was significantly lower in the late than in the early period (3.6% versus 12.5%), whereas pulmonary emphysema was more severe in the late period compared to the early period. Intraoperative failure of sealing air leaks was significantly reduced in the late period than in the early period. In both univariate and propensity score matching analysis, the study period was a significant predictor of prolonged air leak.

CONCLUSIONS

The combination of stitching and covering with mesh may contribute to reducing prolonged air leak incidence in patients undergoing thoracoscopic anatomical lung resection for lung cancer.

Zero-leak prediction during major lung resection aiming for minimal chest drainage duration: a retrospective analysis

BACKGROUND

Early chest tube removal should be considered to enhance recovery after surgery. The current study aimed to provide a predictive algorithm for air leak episodes (ALE) and to create a knowledge base for early chest tube removal.

METHODS

This retrospective study enrolled patients who underwent thoracoscopic anatomical pulmonary resections in our unit. We defined ALE as any airflow ≥ 10 mL/min recorded in the follow-up charts based on the digital thoracic drainage device. Multivariate regression analysis was used to control for preoperative and intraoperative confounding factors. The ALE prediction algorithm was constructed by combining an additive ALE risk-scoring system using the coefficients of the significant predictive factors with the intraoperative water-sealing test.

RESULTS

In 485 consecutive thoracoscopic major pulmonary resections, ALE developed in 209 (43%) patients. Statistically significant ALE-associated preoperative factors included male sex, lower body mass index, radiologically evident emphysema, lobectomy, and upper lobe surgery. Significant ALE-associated intraoperative factors were incomplete fissure and pleural adhesion. The ALE risk scoring demonstrated an average area under the receiver operating characteristic curve of 0.72 in the fivefold cross-validation test. The ALE prediction algorithm correctly predicted ALE-absent patients at a negative predictive value of 80%.

CONCLUSIONS

The algorithm may promote the optimization of the chest tube-dwelling duration by identifying potential ALE-absent patients for accelerated tube removal.

The process and safety of removing chest tubes 4 to 12 hours after robotic pulmonary lobectomy and segmentectomy

Objective

Chest tubes cause pain and morbidity.

Methods

This is a quality initiative study and review of patients who underwent robotic pulmonary resection by 1 surgeon (R.J.C.). The goal was to remove chest tubes within 4 to 12 hours after robotic segmentectomy and lobectomy. Primary outcome was removal without the need for reinsertion, thoracentesis, or any morbidity due to early removal of the chest tube. Secondary outcomes were symptomatic pneumothorax, pleural effusion, chylothorax, subcutaneous emphysema, and chest tube reinsertion or thoracentesis within 60 days of surgery.

Results

Between January 2018 and December 2022, 590 patients underwent robotic lobectomy or segmentectomy. Chest tubes were removed within 4 to 12 hours postoperatively in 63.5% of patients (375/590). In 2022, this was achieved in 91% after lobectomy (119/128) and 94% after segmentectomy (75/80). There were significantly more chest tubes removed within 4 to 12 hours postoperatively from 2020 to 2022 than pre-2020 (P < .001). Forty patients (6.8%) were discharged home on postoperative day 1 with a chest tube. Sixteen patients (2.7%) had post-chest tube removal increasing pneumothorax and subcutaneous emphysema; none required tube reinsertion. There was no 30-day or 90-day mortality. Twelve patients (2%) had an outpatient thoracentesis for effusion within 60 days. Twenty patients (3.3%) were readmitted, none seemingly related to effusions. Nonsmokers (P = .04) and segmentectomy (P = .001) were associated with chest tube removal within 4 to 12 hours of surgery.

Conclusions

Chest tubes can be safely removed within 4 to 12 hours after robotic segmentectomy and lobectomy. Factors associated with successful early chest tube removal are nonsmoking, segmentectomy, and team members becoming comfortable with the process.

Early chest drain removal on the day of uniportal thoracoscopic segmentectomy

OBJECTIVE

Although early removal of postoperative chest drains can facilitate recovery, it can be difficult to achieve in segmentectomy due to the management of air leakage in intersegmental planes. This study prospectively examined the feasibility of drain removal on the same day of uniportal thoracoscopic segmentectomy.

METHODS

Twenty patients who underwent uniportal thoracoscopic segmentectomy between July 2021 and May 2022 were enrolled in this prospective study. The indications for drain removal on the day of surgery were absence of air leakage in an intraoperative sealing test, radiographic evidence of lung expansion, and continuous absence of air leakage via a drainage bottle for 4 h after the operation. The primary endpoint was rate of the patients who required re-drainage after the postoperative drainage tube was removed on the day of surgery. The secondary end points were postoperative pain evaluated using a numerical rating scale on postoperative days 1, 7, and 28; morbidity; and postoperative hospitalization period.

RESULTS

Fifteen patients successfully underwent drain removal on the day of surgery. None required re-drainage. The mean postoperative hospitalization period was 2.3 ± 1.7 days. Overall, 12 of the 15 (80%) patients were discharged on postoperative day 1 or 2. The mean numerical rating scale scores were 1.2 ± 1.6, 0.4 ± 0.7, and 0.4 ± 1.5 on postoperative days 1, 7, and 28, respectively.

CONCLUSION

In uniportal thoracoscopic segmentectomy, drain removal on the day of surgery is feasible and may reduce pain on postoperative day 1.

Feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax patients

OBJECTIVES

Although early removal of postoperative chest drains can facilitate postoperative recovery, there are risks of undetected bleeding and a need for re-drainage to treat delayed pulmonary air leaks. In this study, we aimed to prospectively examine the feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax (PSP) patients.

METHODS

Between January 2021 and November 2021, 30 PSP patients were enrolled in this prospective study. The absence of air leakage was confirmed and radiographic evidence of lung expansion was acquired; the tube was then removed in the operating room. The primary endpoint was postoperative air leakage requiring re-drainage among patients who underwent tube removal in the operating room. The secondary endpoints were postoperative pain (numerical rating scale) on postoperative days (PODs) 1, 7, and 28, morbidity, and postoperative hospitalization time.

RESULTS

Four (13.3%) patients were excluded because of underlying pulmonary disease (n = 2) and air leaks (n = 2) detected in the operating room. Chest drainage tubes were removed in the operating room for the remaining 26 patients; none of them required re-drainage. The mean postoperative hospitalization time was 1.2 ± 0.4 days. The mean numerical rating scale scores were 4.2 ± 2 (median: 4.5), 1.6 ± 1.6 (median: 1), and 0.4 ± 0.8 (median: 0) on PODs 1, 7, and 28, respectively. Only one case of hemoptysis occurred as a postoperative complication.

CONCLUSIONS

Tubeless thoracoscopic bullectomy for PSP is feasible and may reduce the postoperative hospitalization time; however, it does not significantly reduce pain on POD1.

Comparison of perioperative outcomes with or without routine chest tube drainage after video-assisted thoracoscopic pulmonary resection: A systematic review and meta-analysis

Background

In recent years, an increasing number of thoracic surgeons have attempted to apply no routine chest tube drainage (NT) strategy after thoracoscopic lung resection. However, the safety and feasibility of not routinely placing a chest tube after lung resection remain controversial. This study aimed to investigate the effect of NT strategy after thoracoscopic pulmonary resection on perioperative outcomes.

Methods

A comprehensive literature search of PubMed, Embase, and the Cochrane Library databases until 3 January 2022 was performed to identify the studies that implemented NT strategy after thoracoscopic pulmonary resection. Perioperative outcomes were extracted by 2 reviewers independently and then synthesized using a random-effects model. Risk ratio (RR) and standardized mean difference (SMD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. Subgroup analysis and sensitivity analysis were subsequently performed.

Results

A total of 12 studies with 1,381 patients were included. The meta-analysis indicated that patients in the NT group had a significantly reduced postoperative length of stay (LOS) (SMD = -0.91; 95% CI: -1.20 to -0.61; P < 0.001) and pain score on postoperative day (POD) 1 (SMD = -0.95; 95% CI: -1.54 to -0.36; P = 0.002), POD 2 (SMD = -0.37; 95% CI: -0.63 to -0.11; P = 0.005), and POD 3 (SMD = -0.39; 95% CI: -0.71 to -0.06; P = 0.02). Further subgroup analysis showed that the difference of postoperative LOS became statistically insignificant in the lobectomy or segmentectomy subgroup (SMD = -0.30; 95% CI: -0.91 to 0.32; P = 0.34). Although the risk of pneumothorax was significantly higher in the NT group (RR = 1.75; 95% CI: 1.14-2.68; P = 0.01), the reintervention rates were comparable between groups (RR = 1.04; 95% CI: 0.48-2.25; P = 0.92). No significant difference was found in pleural effusion, subcutaneous emphysema, operation time, pain score on POD 7, and wound healing satisfactory (all P > 0.05). The sensitivity analysis suggested that the results of the meta-analysis were stabilized.

Conclusions

This meta-analysis suggested that NT strategy is safe and feasible for selected patients scheduled for video-assisted thoracoscopic pulmonary resection.

Systematic Review Registration

https://inplasy.com/inplasy-2022-4-0026, identifier INPLASY202240026.

Video-assisted thoracoscopic treatment as two-day surgery for lung neoplasms: a propensity-matched analysis

Background

Enhanced recovery after surgery programs have reduced complications and shortened hospital stays after lung resection. This study aimed to determine whether video-assisted thoracoscopic surgery performed as a two-day surgery for lung neoplasms was safe and cost-effective.

Methods

This retrospective, propensity-matched, cohort analysis was conducted from January 2020 to August 2020. Among 959 patients who underwent video-assisted thoracoscopic surgery, 739 underwent inpatient surgery and 220 underwent two-day surgery. Propensity-matched analysis, incorporating preoperative variables, was used to compare postoperative complications, post-discharge follow-up results, and hospitalization costs between the groups.

Results

Propensity matching estimated 218 patients in each group. The mean length of hospital stay was shorter in the two-day surgery group (2.17 ± 0.89 days) than in the inpatient surgery group (6.31 ± 2.13 days) (P < 0.001). Delayed removal of chest tubes accounted for over half of the delayed discharges in the inpatient (17 [54.8%]) and two-day surgery (13 [65.0%]) groups. The postoperative pneumonia/atelectasis incidence was lower in the two-day surgery group than in the inpatient surgery group (P = 0.032). The two-day surgery group patients were readmitted to the hospital due to massive pleural effusion, pneumothorax, fever, severe chest pain, and physical weakness. The mean total hospitalization cost in the two-day surgery group was lower than that in the inpatient surgery group (¥ 33,926.1 versus ¥ 38,422.7, P < 0.001). Basic medical, nursing, drug, laboratory-related, and nonsurgical consumable costs in the two-day surgery group were significantly reduced.

Conclusions

Two-day surgery is a safe, feasible, and cost-effective procedure for selected patients with lung neoplasms when combined with accurate preoperative evaluations, successful intraoperative assessments, and effective postoperative health care guidance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09938-x.

A propensity sore-matched study: Applying a modified chest tube drainage strategy in rapid rehabilitation following uni-portal thoracoscopic pulmonary wedge resection

PURPOSE

This study aimed to compare the value of a modified chest tube drainage strategy to a traditional drainage strategy in single-port thoracoscopic pulmonary wedge resection.

METHODS

From January 2019 to July 2021, we collected clinical data on 405 patients who underwent single-port thoracoscopic pulmonary wedge resection in the No.1 Department of Thoracic Surgery at Fujian Medical University Union Hospital, with 121 (29.9%) cases in the modified drainage strategy group and 284 (70.1%) cases in the traditional drainage strategy group. The propensity score matching method (Match Ratio = 1:1) was used to reduce differences in clinical characteristics between the two groups.

RESULTS

Following 1:1 propensity score matching, 120 matched pairs (240 patients) were included in the study. There was no significant difference in general clinical characteristics between the two groups. There was no statistical difference in intraoperative factors except for operative times (71.42 ± 22.98 min vs. 86.80 ± 36.75 min, p < 0.001). In terms of postoperative factors, there were significant differences in postoperative chest tube duration (0.00 ± 0.00 h vs. 32.68 ± 18.51 h, p < 0.001), total drainage volume (143.03 ± 118.33 ml vs. 187.73 ± 140.82 ml, p = 0.008), postoperative hospital stay (2.61 ± 0.70 days vs. 3.27 ± 1.88 days, p < 0.001), number of additional pain relief (0.14 ± 0.40 vs. 0.42 ± 0.74, p < 0.001), facial pain score (2.7 ± 1.8 vs. 3.6 ± 2.7, p = 0.005) and adverse events (p = 0.046). Furthermore, there was a statistical difference between the two groups regarding CTCAE grade-1 complication, but no statistical difference in CTCAE grade-2 complication.

CONCLUSIONS

A modified drainage strategy in single-port thoracoscopic pulmonary wedge resection is safe and feasible, allowing for less postoperative rehabilitation time, pain relief, reduced postoperative pleural effusion, and reduced clinical workload.

Risk of Pneumothorax Requiring Pleural Drainage after Drainless VATS Pulmonary Wedge Resection: A Systematic Review and Meta-Analysis

OBJECTIVE

Omitting pleural drainage after video-assisted thoracic surgery (VATS) for pulmonary wedge resections has been shown to be a safe approach to enhance recovery. However, major concerns remain regarding the risk of postoperative pneumothoraces requiring surgical interventions. Therefore, our objective was to provide conclusive evidence whether chest tube omission after VATS wedge resection is safe and does not increase the risk of pneumothoraces requiring pleural drainage.

METHODS

Five scientific databases were searched. Studies comparing patients with (CT group) and without chest tube drainage (NCT group) after VATS wedge resection were evaluated. Outcomes included radiographically diagnosed pneumothoraces and pneumothoraces requiring pleural drainage, postoperative complications, hospitalization, and pain scores.

RESULTS

Overall, 9 studies (3 randomized controlled trials) were included (N = 928). Meta-analysis showed significantly more radiographically diagnosed pneumothoraces in the NCT group (risk ratio [RR] = 2.58, 95% confidence interval [CI]: 1.56 to 4.29, P < 0.001; I² = 0%). However, no significant differences were found in postoperative pneumothoraces requiring pleural drainage (RR = 1.72, 95% CI: 0.63 to 4.74, P = 0.29; I² = 0%) or complications (RR = 0.77, 95% CI: 0.39 to 1.52, P = 0.46; I² = 0%). Furthermore, the NCT group showed significantly shorter hospitalization (mean difference = -1.26, 95% CI: -1.56 to -0.95, P < 0.001) with high heterogeneity (I² = 58%, P = 0.02), and lower pain scores on postoperative day 1 (standard mean difference [SMD] = -0.98, 95% CI: -1.71 to -0.25, P = 0.009; I² = 92%) and postoperative day 2 (SMD = -1.28, 95% CI: -2.55 to -0.01, P = 0.05; I² = 96%) compared with the CT group.

CONCLUSIONS

VATS wedge resection without routine chest tube placement is suggested as a safe and less invasive approach in selected patients that does not increase the risk of a pneumothorax requiring pleural drainage.

Safety and feasibility study of uniportal video-assisted thoracoscopic pulmonary wedge resection without postoperative chest tube drainage: a retrospective propensity score-matched study

OBJECTIVES

The aim of this study was to assess the impact of postoperative chest tube drainage (CTD) on safety and postoperative recovery by comparing patients with pulmonary nodule undergoing uniportal video-assisted thoracoscopic pulmonary wedge resection with and without postoperative CTD.

METHODS

We retrospectively analysed the data of patients who underwent video-assisted thoracoscopic pulmonary wedge resection for pulmonary nodule at our hospital between 2018 and 2022. In cases where a 12-Fr chest tube was used following the procedure, the tube was not usually removed until the day after surgery. Therefore, the eligible patients were categorized into the drainage tube or the no-drainage tube group according to the use of postoperative CTD. Propensity score matching at a ratio of 1:1 was performed using clinicopathologic and demographic variables. The highest postoperative pain score, postoperative complication rate, postoperative length of stay and hospitalization costs were compared between the 2 groups.

RESULTS

A total of 275 eligible patients, including 150 and 125 patients in the drainage tube and no-drainage tube groups, respectively, were included in the study. After propensity score matching, there were 102 patients in each group. The postoperative complication rate during hospitalization and at 1 week and 1 month after discharge were not significantly different between the 2 groups (P > 0.05 for all). The highest postoperative pain score was significantly lower in the no-drainage tube group than in the drainage tube group [2.02 (standard deviation: 0.81) days vs 2.31 (standard deviation: 0.76) days, P = 0.008]. The postoperative length of stay was significantly shorter in the no-drainage tube group than in the drainage tube group {3.00 [interquartile ranges (IQRs): 2.00-4.00] days vs 2.00 (IQRs: 1.00-3.00) days, P < 0.001}. Similarly, the total hospitalization costs were significantly lower in the no-drainage tube group than in the drainage tube group [33283.74 (IQRs: 27098.61-46718.56) yuan vs 26598.67 (IQRs: 22965.14-29933.67) yuan, P < 0.001].

CONCLUSIONS

Omission of postoperative CTD was safe and feasible in patients with pulmonary nodule undergoing wedge resection. The no-postoperative-drainage policy can substantially shorten the length of hospital stay and reduce the postoperative pain and hospitalization costs without increasing the risk of postoperative complications.

Drainless Thoracoscopic Lobectomy for Lung Cancer

OBJECTIVES: Drainless video-assisted thoracoscopic (VATS) wedge resection has been demonstrated as feasible in treating various lung diseases. However, it remains unknown whether this surgical technique can be effectively applied to lobectomy. In the current study, we evaluated the perioperative outcome of drainless, minimally invasive lobectomy in patients with lung cancer. METHODS: A total of 26 lung cancer patients who received surgery-performed pulmonary lobectomy were enrolled. The perioperative outcomes were analyzed based on a propensity score matching a comparison with those who had chest drainage. RESULTS: No major surgical morbidity and mortality was noted during the perioperative period. The mean of postoperative hospital stay was 5.08 ± 2.48 days. There was no significant difference in postoperative hospital stay between the two groups of patients. However, the presence of significant postoperative pain (VAS score > 30) on the first day after surgery was less in the drainless group (34.6% vs. 3.8%; p = 0.005). CONCLUSIONS: Our results demonstrated that drainless, minimally invasive lobectomy for selected lung cancer patients is feasible. Further evaluation of its impact on short- and long-term surgical outcomes is required in the future.

AAAPT Diagnostic Criteria for Acute Thoracic Surgery Pain

Patients undergoing thoracic surgery experience particular challenges for acute pain management. Availability of standardized diagnostic criteria for identification of acute pain after thoracotomy and video assisted thoracic surgery (VATS) would provide a foundation for evidence-based management and facilitate future research. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the United States Food and Drug Administration, the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address absence of acute pain diagnostic criteria. A multidisciplinary working group of pain experts was invited to develop diagnostic criteria for acute thoracotomy and VATS pain. The working group used available studies and expert opinion to characterize acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms). The resulting diagnostic criteria will serve as the starting point for subsequent empirically validated criteria. PERSPECTIVE ITEM: This article characterizes acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (ie, core diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms).

[Thoracic Surgery Without Chest Tube: The Current Situation in Germany]

BACKGROUND

Over the last decades, several techniques have been implemented to reduce the invasiveness of thoracic surgery. Omitting chest tubes can lead to less postoperative pain and a shorter length of hospital stay. This study examines the extent to which German surgeons use the tubeless technique and what experience they have had with it.

MATERIALS AND METHODS

We conducted a nationwide survey, supported by the German Society of Thoracic Surgery (DGT). A digital questionnaire was sent to all leading thoracic surgeons with DGT membership between July and September 2020.

RESULTS

63 of 161 surgeons (39%) returned the questionnaires. The tubeless technique was used in 1.9% of thoracic surgery procedures performed last year. 59% of hospitals have implemented the technique; 24% of them also performed lung resections that way. The majority of respondents (79%) believe that the tubeless technique causes less postoperative pain; 16% see no advantage. Pleural effusion was ranked as the most important contraindication (76%). All participating surgeons agree that the absence of an air fistula is a prerequisite for performing lung resections using the tubeless technique - commonly checked by an underwater leak test (73%), and/or with a digital drainage system (53%), partially under pressure controlled ventilated lungs. Almost half of the respondents (46%) have not observed any complications using the tubeless technique.

CONCLUSION

Most German thoracic surgeons consider the tubeless technique safe and advantageous over the conventional technique. However, the case load is low and only 59% of the surgeons surveyed have experience with this technique. Randomised clinical trials concerning selection criteria and the procedural pathway may help increase the use.

Postoperative Air Leaks After Lung Surgery: Predictors, Intraoperative Techniques, and Postoperative Management

Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.

Is tubeless uniportal video-assisted thoracic surgery for pulmonary wedge resection a safe procedure?

OBJECTIVES

Tubeless uniportal video-assisted thoracic surgery (VATS), using a uniportal approach and non-intubated anaesthesia while avoiding postoperative chest drain insertion, for patients undergoing thoracoscopic surgery has been demonstrated to be feasible in selected cases. However, to date, the safety of the procedure has not been studied.

METHODS

We reviewed consecutive patients undergoing non-intubated uniportal VATS for pulmonary wedge resection at 2 medical centres between August 2016 and October 2019. The decision to avoid chest drain insertion was made in selected candidates. For those candidates in whom a tubeless procedure was performed, postoperative chest X-rays (CXRs) were taken on the day of the surgery [operation (OP) day], on postoperative day 1 and 1-2 weeks later. The factors associated with abnormal CXR findings were studied.

RESULTS

Among 135 attempts to avoid chest drain insertion, 13 (9.6%) patients ultimately required a postoperative chest drain. Among 122 patients in which a tubeless procedure was performed, 26 (21.3%) and 47 (38.5%) had abnormal CXR findings on OP day and postoperative day 1, respectively. Among them, 3 (2.5%) patients developed clinically significant abnormal CXRs and required intercostal drainage. Primary spontaneous pneumothorax was independently associated with a higher risk of postoperative abnormal CXRs.

CONCLUSIONS

Tubeless uniportal VATS for pulmonary wedge resection can be safely performed in selected patients. Most patients with postoperative abnormal CXRs presented subclinical symptoms that spontaneously resolved; only 2.5% of patients with postoperative abnormal CXRs required drainage.

Efficacy and safety of omitting chest drains after video-assisted thoracoscopic surgery: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to determine the efficacy and safety of omitting chest drains compared to routine chest drain placement after video-assisted thoracoscopic surgery (VATS).

METHODS

Five bibliographic databases, ClinicalTrials.gov and PROSPERO were comprehensively searched from inception to July 29, 2020 (no language restrictions). Postoperative outcomes were extracted and synthesized complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Risk of bias (RoB) including non-reporting bias, heterogeneity, and sensitivity were assessed. Subgroup analyses were performed based on study design.

RESULTS

Of 7,166 identified studies, 10 studies [four randomized controlled trials (RCTs) and six non-RCTs] with 1,079 patients were included. There were 561 patients in the no chest drain group (NCD) and 518 patients in the standard chest drain group (CD). In pairwise analysis the NCD group had significant shorter length of stay (LOS) [weighted mean difference (WMD) -1.53 days, P<0.001], less postoperative pain scores (WMD -1.09, P=0.002), but higher risk of drain insertion or thoracocentesis [risk radio (RR) 3.02, P=0.040]. There were no significant differences on the incidence of minor pneumothorax (RR 1.77, P=0.128), minor pleural effusion (RR 1.88, P=0.219), minor subcutaneous emphysema (RR 1.37, P=0.427) or pneumonia (RR 0.53, P=0.549). No mortality was observed in either group during the observation period (in-hospital or 30-day mortality).

CONCLUSIONS

Omitting chest drains in selected patients after VATS seems effective leading to enhanced recovery with shorter length of postoperative stay and less pain but with a higher risk of drain insertion or thoracocentesis. However, a major part of the evidence comes from observational studies with high RoB. Further RCTs are needed to improve the current evidence.

Early removal or avoiding the use of perioperative indwelling urinary catheters with spontaneous pneumothorax surgery

OBJECTIVES

The study evaluated the safety and advantages of no using urinary catheters (UCs) during the perioperative period in patients undergoing spontaneous pneumothorax surgery.

METHODS

Forty-one patients aged 30 years or younger who underwent spontaneous pneumothorax surgery at our hospital between January 2018 and March 2020 were screened. Patients with postoperative recurrence were excluded. Patients were divided into three groups: the indwelling UC group (n = 10, group A), the group with UC removal in the operating room before extubation (n = 23, group B), and the no UC group (n = 8, group C). Perioperative circulatory complications, UC insertion or re-insertion, and time to getting out of bed after surgery and confirmation of initial urination were investigated by group.

RESULTS

There were no perioperative UC insertions or re-insertions, or perioperative circulatory problems in any group. The median time (interquartile range) required for confirmation of initial postoperative urination was shorter in groups B and C [group A: 13.5 (10.6, 17.3) vs group B: 6.0 (5.0, 6.8) vs group C: 5.5 (3.8, 6.8) h; p = 0.01]. However, the time to getting out of bed after surgery was not significantly different [10.5 (6.4, 15) vs 6.0 (5.0, 7) vs 5.0 (3.8, 8) h; p = 0.12)]. Multivariable analysis showed that group A had a significantly different time to confirmation of initial urination (p = 0.001).

CONCLUSIONS

Postoperative and intraoperative avoidance of indwelling UC use is acceptable in spontaneous pneumothorax surgery that satisfies certain conditions. Avoiding UC use has the potential to improve the patient experience and facilitate postoperative management.

Early postoperative day 0 chest tube removal using a digital drainage device protocol after thoracoscopic major pulmonary resection

OBJECTIVES

The aim of this study was to assess the safety of early chest tube removal on postoperative day 0 (POD 0) on the basis of a digital drainage device protocol in patients undergoing thoracoscopic major lung resection and its contribution as a component of an enhanced recovery after surgery programme.

METHODS

One hundred consecutive patients who underwent thoracoscopic lobectomy or segmentectomy were submitted to the following criteria for chest tube removal: Air flow ≤20 ml/min for at least 4 h without fluid threshold, except if haemorrhagic or chylous. Two groups were defined according to chest tube removal on POD 0 (G0) or POD ≥1 (G1). Primary outcome was pleural complication and secondary outcomes were cardiopulmonary complication, length of drainage, length of stay (LOS), compliance with opioid-free analgesic protocol and readmission. The follow-up was 90 days from discharge.

RESULTS

The chest tube was removed on POD 0 in 45% of patients (G0). None of them required tube reinsertion for pneumothorax and 1 patient was readmitted for a delayed pleural effusion. Among the 55% remaining patients (G1), the median length of drainage was 2 days, including 3 prolonged air leaks (>5 days). G0 and G1 were not different in terms of cardiopulmonary complication and readmission (6.6% vs 9% and 4.4% vs 7.2%, respectively). The median LOS was 1 day in G0 and 2 days in G1. The compliance with opioid-free analgesic protocol was significantly higher (75% vs 45%, P = 0.004) in G0 compared to G1.

CONCLUSIONS

Early POD 0 chest tube removal after thoracoscopic major pulmonary resection is safe in selected patients on the basis of a digital drainage device protocol. Also, it may contribute, by reducing early postoperative pain, to enhance postoperative recovery as part of an advanced enhanced recovery after surgery programme.

No drains in thoracic surgery with ERAS program

Enhanced recovery after lobectomy surgery (ERAS) concept has been greatly developed between clinical implementation and minimally invasive surgery. In addition to the minimally invasive surgery, the management of the perioperative catheter has also attracted everyone’s attention. Tubeless minimally invasive treatment includes no urinary catheter placement during the operation and no chest tube after the operation. Here, we summarized all the reports on no urinary catheterization and no chest tube in patients with thoracic surgery and the impact of postoperative length of stay (LOS) and postoperative complications. We find that avoiding chest drain and urinary catheter placement after the surgery appears to be safe and beneficial for patients.

Augmented fluoroscopic bronchoscopy (AFB) versus percutaneous computed tomography-guided dye localization for thoracoscopic resection of small lung nodules: a propensity-matched study

BACKGROUND

Dye localization is a useful method for the resection of unidentifiable small pulmonary lesions. This study compares the transbronchial route with augmented fluoroscopic bronchoscopy (AFB) and conventional transthoracic CT-guided methods for preoperative dye localization in thoracoscopic surgery.

METHODS

Between April 2015 and March 2019, a total of 231 patients with small pulmonary lesions who received preoperative dye localization via AFB or percutaneous CT-guided technique were enrolled in the study. A propensity-matched analysis, incorporating preoperative variables, was used to compare localization and surgical outcomes between the two groups.

RESULTS

After matching, a total of 90 patients in the AFB group (N = 30) and CT-guided group (N = 60) were selected for analysis. No significant difference was noted in the demographic data between both the groups. Dye localization was successfully performed in 29 patients (96.7%) and 57 patients (95%) with AFB and CT-guided method, respectively. The localization duration (24.1 ± 8.3 vs. 21.4 ± 12.5 min, p = 0.297) and equivalent dose of radiation exposure (3.1 ± 1.5 vs. 2.5 ± 2.0 mSv, p = 0.130) were comparable in both the groups. No major procedure-related complications occurred in either group; however, a higher rate of pneumothorax (0 vs. 16.7%, p = 0.029) and focal intrapulmonary hemorrhage (3.3 vs. 26.7%, p = 0.008) was noted in the CT-guided group.

CONCLUSION

AFB dye marking is an effective alternative for the preoperative localization of small pulmonary lesions, with a lower risk of procedure-related complications than the conventional CT-guided method.

Comparison of the results of two chest tube managements during an enhanced recovery program after video-assisted thoracoscopic lobectomy: A randomized trial

BACKGROUND

This study compared the results of the application of two different chest tube management systems; a drainage ball with low negative pressure and the more commonly used chest tube with water-sealed bottle, after video-assisted thoracoscopic (VATS) lobectomy.

METHODS

A total of 60 patients undergoing lobectomy were enrolled into this prospective open label randomized clinical trial and equally divided into two groups. The data collected in the trial included age, gender, forced expiratory volume in 1 second (FEV1), blood loss, operation time, drainage volume, drainage time, length of stay, postoperative pain score according to the Visual Analogue Scale (VAS) within 24 hours after surgery and chest tube removal. This study was registered at ClinicalTrials.gov (NCT03598296).

RESULTS

The characteristics of the patients were similar in both groups. Group ball patients had a lower pain score (after operation: 3.47 ± 1.80 vs. 6.20 ± 1.56, P < 0.001; after removal of chest tube: 1.47 ± 1.28 vs. 3.00 ± 1.29, P < 0.001); less analgesic used (2.83 ± 2.09 times vs. 5.00 ± 3.24 times, P = 0.003); less drainage time (upper tube: 3.89 ± 1.63 days vs. 5.10 ± 2.02 days, P = 0.048; lower tube: upper lobe 4.84 ± 1.61 days vs. 5.90 ± 1.52 days, P = 0.041; lower lobe: 3.82 ± 1.08 days vs. 5.70 ± 2.63 days, P = 0.042) and shorter length of stay (5.40 ± 1.65 days vs. 6.37 ± 1.99 days, P = 0.045). All other related parameters were similar in both groups.

CONCLUSIONS

For patients undergoing lobectomy, using a drainage ball with negative pressure could reduce hospitalization days and postoperative pain compared with the more commonly used chest tube with water-sealed bottle when a strict postoperative curative procedure was performed.

A chest tube may not necessary in children thoracoscopic lobectomy

Drainage of the thorax postoperatively using chest tubes is a standard procedure in thoracic surgery. However, chest tubes can induce pain and immobilization, increase risk of infection, deteriorate the ventilation capacity, and increase difficulty of postoperative management, particularly in children. This study aimed to investigate the safety and effect of excluding chest tubes after performing thoracoscopic lobectomy in selected children.A retrospective review of medical records was performed in West China Hospital of Sichuan University from January 2014 to June 2018. Patients who underwent thoracoscopic lobectomy without chest tubes were recorded. Patients with accompanying severe pulmonary infection, extensive thoracic adhesions, or undeveloped interlobar fissure were excluded.In total, 246 patients underwent thoracoscopic lobectomy without a chest tube, and none required chest drain insertion or reintervention during hospitalization and follow-up at 90 days postoperatively. Among them, 2 (0.81%) patients developed a delayed pneumothorax which was found after being discharged, and resolved spontaneously in 2 weeks. No hemothorax, atelectasis, and bronchial fistula were found. Furthermore, 202 (82.1%) patients developed subcutaneous emphysema, which was asymptomatic and spontaneously resolved within 3 to 7 days. The length of postoperative hospital stay was 2 days; patients were discharged in the 3rd day postoperatively. Patients could recover to free mobilization and resume regular diet at 6 hours postoperatively. All patients were followed up for at least 3 months; no other complications were found, and all patients recovered well.This study showed that chest tube placement in selected patients may be unnecessary in children undergoing thoracoscopic lobectomy. The minimally invasive procedure and meticulous resection have been the preconditions of this procedure, which may contribute to a rapid recovery and can avoid the chest tube-related complications effectively.

Is a Chest Tube Necessary after Video-Assisted Thoracoscopic Mediastinal Tumor Resection?

BACKGROUND

The omission of chest tubes after thoracoscopic procedures such as sympathectomy, lung biopsy, and lung resection has proven efficacious in decreasing pain and length of hospital stay in some cases. However, its safety for mediastinal diseases remains unclear. This study evaluated the feasibility and outcome of eliminating chest drains after video-assisted thoracoscopic surgery (VATS) for mediastinal tumor resection.

METHODS

We retrospectively investigated 70 patients receiving VATS mediastinal tumor resection in a single institution between January 2016 and November 2018. A total of 39 patients (drain group) received postoperative chest drains and 31 patients (no-drain group) did not. Group clinical outcomes and operation data were compared. A propensity score matching analysis was further performed to yield a fairer comparison.

RESULTS

Before propensity score matching, the no-drain group had a higher prevalence of cystic lesions, a shorter operative time, and less blood loss compared with the drain group (p = 0.015, p = 0.018, and p < 0.001, respectively). After matching, the group differences in these perioperative variables lost significance (p = 0.095, 0.4, and 0.2, respectively). The no-drain group had lower postoperative day 2 pain scores and shorter postoperative hospital stays than the drain group, regardless of whether they were matched (pain: p = 0.028; hospital stay < 0.001) or not (pain: p = 0.003; hospital stay < 0.001). No major adverse events occurred in either group during hospitalization or follow-up period.

CONCLUSION

Eliminating chest drain placement after VATS mediastinal tumor resection may benefit some patients and decrease postoperative pain and hospital stay without increasing complications or compromising patient safety.

"No drain" uniportal thoracoscopic resection for posterior mediastinal paravertebral Mullerian cyst

Mediastinal Mullerian cyst was first reported by Hattori in 2005. We report a case of a posterior mediastinal paravertebral cyst found incidentally by surveillance chest roentgenogram in a 44-year-old woman. She had a "no drain" uniportal thoracoscopic removal procedure, and histologic examination showed single layer of columnar epithelial lining that stained positive for estrogen receptors (ER), progesterone receptors (PR), paired box gene 8 (PAX8), and Wilms' tumor protein 1 (WT-1), confirming the diagnosis of mediastinal Mullerian cyst.

Tubeless single-port thoracoscopic sublobar resection: indication and safety

Background

The tubeless technique, defined as non-intubated general anesthesia with omission of chest drainage after video-assisted thoracoscopic surgery (VATS), is a new concept to further minimize surgical trauma. However, there has been little investigation into the associated feasibility and safety. Minimization of postoperative pneumothorax is challenging. We set up a "tubeless protocol" to select patients for tubeless single-port VATS with monitoring of a digital drainage system (DDS).

Methods

From November 2016 to September 2017, 50 consecutive non-intubated single-port VATS for pulmonary resection were performed. In our study, patients with small and peripheral pulmonary lesions indicated for sublobar resections, as diagnostic or curative intent, were included. After excluding patients having tumors >2 cm, or intrapleural adhesions noted during operation, or forced expiratory volume in the 1 second <1.5 L, 36 patients were selected for tubeless protocol. The clinical characteristics and perioperative outcomes of these patients are presented.

Results

Among 36 cases, 5 patients had minor air leaks detected using the DDS and required intercostal drainage after wound closure. Among the remaining 31 patients in whom the DDS showed no air leak, the chest drainage was removed immediately after wound closure. A postoperative chest roentgenogram on the surgery day showed full expansion in all patients without pneumothorax. Only 7 (19.4%) patients developed minor subclinical pneumothorax on the first postoperative day without the need for chest drainage. All patients were discharged uneventfully without the need for intervention.

Conclusions

Our tubeless protocol utilizes DDS to select patients who can have intercostal drainage omitted after non-intubated single-port VATS for pulmonary resection. Using objective DDS parameters, we believe that this is an effective way to reduce the rate of pneumothorax after tubeless single-port VATS in selected patients.

It is safe and feasible to omit the chest tube postoperatively for selected patients receiving thoracoscopic pulmonary resection: a meta-analysis

Background

To access the feasibility and safety of no chest tube (NCT) placement after thoracoscopic pulmonary resection.

Methods

A comprehensive search of online databases (PubMed, Embase, Web of Science, and Cochrane library) was performed. Studies investigating the safety and feasibility of NCT compared with chest tube placement (CTP) after VATS pulmonary resection were eligible for our meta-analysis. Perioperative outcomes were extracted and synthesized. Specific subgroups (wedge resection) were examined. The methodological quality of the included articles was evaluated with the methodological index for non-randomized studies (MINORS) tool.

Results

Analysis of 9 studies including a total of 918 patients was performed. Four hundred sixty-one patients underwent NCT and 457 patients underwent CTP. The length of stay (LOS) postoperatively in the NCT group was significant shorter than in the CTP group [standardized mean difference (SMD) = -0.80; 95% confidence interval (CI), -1.13 to -0.47, P=0.000]. Patients in the NCT group experienced slighter pain than patients in the CTP group in postoperative day (POD) one (SMD = -0.41; 95% CI, -0.75 to -0.07, P=0.02), and POD two (SMD = -0.41; 95% CI, -0.75 to -0.07, P=0.02). While, there was no significant difference about the 30-day morbidity for patients who underwent NCT and CTP [relative ratio (RR) =1.01; 95% CI, 0.59-1.74, P=0.04) and the rate of re-intervention (RR =0.89; 95% CI, 0.33-2.40, P=0.57). No perioperative mortality was observed in both groups. The sensitivity analysis suggested that the relative effects between 2 groups have already stabilized. Subgroup analysis revealed an effect modification by operation approach regarding perioperative morbidity, but not for LOS.

Conclusions

This meta-analysis conforms that it is feasible and safe to omit chest tube after thoracoscopic pulmonary resection for patients carefully selected. Randomized controlled trails (RCTs) are urgently needed to verify this conclusion.

[Video-assisted thoracic surgery : A global development]

More than 200 years ago the first attempts at thoracoscopy were made but only after its introduction 25 years ago has video-assisted thoracoscopic surgery (VATS) experienced rapid progress. Due to worldwide cooperation and international networking tremendous progress of the technique was made by thoracic surgeons on all continents developing the technique into a less invasive operating procedure on the thorax. For patients this meant improvement in the quality of life and ultimately better survival rates following lung cancer surgery. The VATS procedures are nowadays the preferred method unless the size and extent of the tumor prohibits a minimally invasive procedure. New trends in VATS are ambulatory, drainless or uniportal VATS, the latter being possible because insufflation of carbon dioxide is not necessary, allowing manipulation with multiple instruments through one small incision. The other trend is robotic-assisted thoracic surgery. The benefits of the robotics are higher degrees of freedom for movement of the instruments. The development of VATS is nowadays a global one with North America and Asian countries being the most active protagonists, but European countries also play an important role in shaping the future of minimally invasive surgery. Modern media help to further promote the technique.

Low-voltage coagulation, polyglycolic acid sheets, and fibrin glue to control air leaks in lung surgery

OBJECTIVE

We evaluated the efficacy of low-voltage coagulation (LVC) with polyglycolic acid (PGA) sheets (Neoveil, GUNZE Ltd., Japan) and fibrin glue to control intraoperative alveolar air leaks after lung surgery.

METHODS

We included 176 patients with non-small cell lung cancer who underwent thoracoscopic lobectomies. When alveolar air leak was confirmed after lung resection, we applied LVC system to the pleural defect followed by layers of PGA sheets and fibrin glue (n = 40). We then analyzed postoperative air leaks (rate of occurrence and duration time).

RESULTS

73% of patients (29/40 cases) experienced no postoperative air leaks. Although 11 patients experienced air leaks after surgery, there were no prolonged air leaks (>7 days) (resolution time, 3.5 ± 1.4 days; range, 2-6 days). Two patients required drainage for late-onset air leaks, but their conditions improved without further treatment. There were no further adverse events.

CONCLUSIONS

The use of LVC with PGA sheets and fibrin glue following pulmonary resection efficiently prevented both intraoperative air leaks and prolonged air leaks after lung surgery.