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

Why do patients stay in hospital after enhanced recovery thoracoscopic wedge resection? A prospective observational study

OBJECTIVES

This single-centre prospective observational study aimed to investigate reasons for prolonged hospitalization [over the median length of stay (LOS)] after enhanced recovery thoracoscopic [ERAS 3-port video-assisted thoracoscopic surgery (VATS)] wedge resection.

METHODS

All patients were evaluated twice-daily by an investigator for reasons of hospitalization. Each reason was analysed individually. Predictors for prolonged hospitalization were identified using a multivariable backward stepwise logistic regression model.

RESULTS

A total of 150 consecutive patients (lymphadenectomy 8.7%) were included from November 2022 to December 2023, with a median LOS of 1 (interquartile range 1-2) day. Of these, 55 patients (36.7%) experienced prolonged hospitalization. The main reasons included postoperative pain (16.0%), air leak (14.7%) and social factors (14.7%), followed by oxygen dependency (7.3%), gastrointestinal factors (5.3%), urinary factors (4.7%), pneumonia (1.3%), pleural effusion (1.3%), chylothorax (0.7%), atrial fibrillation (0.7%), confusion (0.7%) and fatigue (0.7%). Multivariable analysis revealed that an increase in the percentage of predicted forced expiratory volume in 1 s (FEV1%pre) by 1% [odds ratio (OR) 0.41, P = 0.023) and percentage of predicted diffusing capacity for carbon monoxide (DLCO%pre) by 1% (OR 0.95, P = 0.002) decreased likelihood of prolonged hospitalization. Conversely, each additional pack-year (OR 1.01, P = 0.028) and living alone (OR 3.55, P = 0.005) increased the risk of prolonged hospitalization.

CONCLUSIONS

Prolonged hospitalization (LOS > 1 day) after ERAS 3-port VATS wedge resection, with 8.7% lymphadenectomy, was mainly due to pain, air leak and social factors. Smokers with decreased FEV1%pre or DLCO%pre and patient living alone were at increased risk.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT06118593 (https://clinicaltrials.gov/study/NCT06118593?cond=why%20in%20hospital&rank=2).

Readmission after enhanced recovery video-assisted thoracoscopic surgery wedge resection

BACKGROUND

Despite the implementation of Enhanced Recovery After Surgery (ERAS) programs, surgical stress continues to influence postoperative rehabilitation, including the period after discharge. However, there is a lack of data available beyond the point of discharge following video-assisted thoracoscopic surgery (VATS) wedge resection. Therefore, the objective of this study is to investigate incidence and risk factors for readmissions after ERAS VATS wedge resection.

METHODS

A retrospective analysis was performed on data from prospectively collected consecutive VATS wedge resections from June 2019 to June 2022. We evaluated main reasons related to wedge resection leading to 90-day readmission, early (occurring within 0-30 days postoperatively) and late readmission (occurring within 31-90 days postoperatively). To identify predictors for these readmissions, we utilized a logistic regression model for both univariable and multivariable analyses.

RESULTS

A total of 850 patients (non-small cell lung cancer 21.5%, metastasis 44.7%, benign 31.9%, and other lung cancers 1.9%) were included for the final analysis. Median length of stay was 1 day (IQR 1-2). During the postoperative 90 days, 86 patients (10.1%) were readmitted mostly due to pneumonia and pneumothorax. Among the cohort, 66 patients (7.8%) had early readmissions primarily due to pneumothorax and pneumonia, while 27 patients (3.2%) experienced late readmissions mainly due to pneumonia, with 7 (0.8%) patients experiencing both early and late readmissions. Multivariable analysis demonstrated that male gender, pulmonary complications, and neurological complications were associated with readmission.

CONCLUSIONS

Readmission after VATS wedge resection remains significant despite an optimal ERAS program, with pneumonia and pneumothorax as the dominant reasons. Early readmission was primarily associated with pneumothorax and pneumonia, while late readmission correlated mainly with pneumonia.

Efficacy of avoiding chest drains after video-assisted thoracoscopic surgery wedge resection: protocol for a randomised controlled trial

INTRODUCTION

The use of routine postoperative chest drains after video-assisted thoracoscopic surgery (VATS) of the lung is a practice based on tradition with the aim of draining fluid and air. However, new evidence suggests that chest drains can be avoided in selected cases. With this randomised controlled trial, we wish to establish the efficacy and safety of avoiding postoperative chest drains compared with routine postoperative chest drains.

METHODS AND ANALYSIS

This is a two-centre randomised controlled trial without allocation concealment, but where randomisation occurs after the end of procedure leaving operative personnel blinded during surgery. The sample size is calculated to show a difference in pain measurements using the Numeric Rating Scale under different circumstances and at different time points to show superiority of the intervention. The trial is pragmatic by design to reflect the daily clinical scenario and with the aim of increasing the external validity of the results.

ETHICS AND DISSEMINATION

Approval by the local ethics committees has been obtained for both sites. The study was registered with ClinicalTrials.gov (NCT05358158) prior to inclusion. The results of the trial will be disseminated by publication in an international journal and presentation at major international thoracic surgical meetings.

ARTICLE SUMMARY

This is a randomised controlled trial estimating the effects of avoiding a chest drain after VATS wedge resection of the lung on pain, total morphine use, quality of life and complications.

TRIAL REGISTRATION NUMBER

NCT05358158.

Are chest drains routinely required after thoracic surgery? A drainology study of on-table chest-drain removals

Objectives

Advances in perioperative management for thoracic surgery have accelerated the postoperative recovery of patients by decreasing postoperative pain and the incidence of complications. We aimed to study whether it's safe to remove chest drains on table in selected cases.

Methods

This was a 5-year retrospective analysis of protocolized chest-drain removal on the operating table. The chest drain was removed in patients undergoing sublobar/wedge lung resection and other minor thoracic procedure (pleural biopsy, mediastinal mass biopsy/resection) via a thoracoscopic approach (video-assisted thoracoscopic surgery). Chest drains were removed at the end of the operation if air leak as documented by the digital drain was less than 20 mL/min. Outcome data on postdrain removal pneumothorax, effusion, and need for further intervention were obtained by reviewing the postoperative chest films, all reported by a radiologist.

Results

Between 2016 and 2021, 107 patients underwent drain removal in theater. Mean age (standard deviation) was 58 (17) years and 54 (50.5%) were male. Postdrain removal pneumothorax occurred in 22 patients (21%), pleural effusion in 6 (5.6%), and 21 of 22 postoperative pneumothoraces were managed conservatively without reinsertion of chest drain. As it is our standard policy to leave no pneumothorax in patients undergoing surgical management of primary spontaneous pneumothorax, only 1 such patient (0.9%) had a drain reinserted as a result. The median (interquartile) length of hospital stay was 1 day (1-2), and 14 patients (13%) were discharged on surgery day.

Conclusions

Our results demonstrate that on table chest-drain removal in selected cases is safe and repeatable using a digital drain, challenging the practice of routine drain insertion after thoracic surgery.

Days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in the era of enhanced recovery

BACKGROUND

Days alive and out of hospital is proposed as a valid and patient-centred quality measure for perioperative care. However, no procedure-specific data exist after pulmonary wedge resection. The aim of this study was to assess the first 90 days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in an optimized enhanced recovery programme.

METHODS

A retrospective analysis of prospectively collected data of consecutive patients undergoing enhanced recovery thoracoscopic wedge resections from January 2021 to June 2022 in a high-volume centre was carried out. All factors leading to hospitalization, readmission, and death were evaluated individually. A logistic regression model was used to evaluate predictors. Additionally, a sensitivity analysis was performed.

RESULTS

A total of 433 patients were included (21.7% (n = 94) with non-small cell lung cancer, 47.6% (n = 206) with metastasis, 26.8% (n = 116) with benign nodules, and 3.9% (n = 17) with other lung cancers). The median duration of hospital stay was 1 day. The median of postoperative 30 and 90 days alive and out of hospital was 28 and 88 days respectively. Air leak (112 patients) and pain (96 patients) were the most frequent reasons for reduced days alive and out of hospital from postoperative day 1 to 30, whereas treatment of the original cancer or metastasis (36 patients) was the most frequent reason for reduced days alive and out of hospital from postoperative day 31 to 90. Male sex, reduced lung function, longer dimension of resection margin, pleural adhesions, and non-small cell lung cancer were independent risks, confirmed by a sensitivity analysis.

CONCLUSION

Days alive and out of hospital within 90 days after enhanced recovery thoracoscopic wedge resection was only reduced by a median of 2 days, mainly due to air leak and pain.

A No-Chest-Drain Policy After Video-assisted Thoracoscopic Surgery Wedge Resection in Selected Patients: Our 12-Year Experience

BACKGROUND

Postoperative pleural drainage omission after video-assisted thoracoscopic surgery (VATS) for wedge resections may facilitate faster recovery. This retrospective cohort study presents our 12-year experience with omitting thoracic drainage in patients who underwent a VATS wedge resection, aiming to assess its safety and efficacy.

METHODS

Records from consecutive patients who underwent a VATS wedge resection at our hospital between February 2008 and October 2020 were retrospectively reviewed and assessed for eligibility. Patient and surgical characteristics as well as postoperative data were collected and compared between patients who received a chest drain (CD) or received no chest drain (NCD) after surgery. Univariable and multivariable analyses were performed to determine whether drain placement was associated with complications (primary outcome), and major complications requiring pleural drainage or length of hospital stay (secondary outcomes).

RESULTS

Data of 348 patients were analyzed. The drainless group (n = 98) and drain group (n = 237) were significantly different in the following baseline and surgical characteristics: sex, pulmonary function, interstitial lung disease, final pathology, number of wedges, and surgical approach. No significant differences were detected in postoperative complications (NCD 8.2%, CD 14.8%; P = .10), major complications (NCD 5.1%, CD 5.1%; P > .99), or complications requiring pleural drainage (NCD 5.1%, CD 3.8%; P = .56). The drainless group did show a significantly shorter hospitalization (NCD 2 ± 2, CD 3 ± 2 days; P < .001). Multivariable analyses revealed that drain placement was not significantly correlated with postoperative complications. In contrast, prolonged hospitalization was significantly influenced by drain placement.

CONCLUSIONS

Our findings suggest that a no-chest-drain policy after VATS wedge resections can safely fast-track rehabilitation for selected patients.

Enhanced recovery after surgery and chest tube management

This review documents the relationships between enhanced recovery after surgery (ERAS) pathways, chest tube management and patient outcomes following lung resection surgery. ERAS pathways have been introduced to mitigate the harmful stress response that occurs following all major surgery, including lung resection. Improvements to the entire patient pathway, from the preoperative admission clinic through to discharge and beyond, can have additive or synergistic effects and result in improved patient outcomes, reduced length of stay and lower costs. At the same time, there are some key care elements that appear to be more important than others. In the postoperative period, early removal of chest tubes, early mobilization, and limited use of opioids are all independently important factors. These elements of care are all intertwined. Therefore, a focus on proactive chest tube management with the abandonment of conservative chest tube strategies should be a focus of postoperative ERAS pathways. This can be achieved with single tubes, no routine suction, the use of digital drainage systems, and removal of tubes even in the presence of relatively high serous pleural fluid outputs. The goals of early mobilization and opioid-sparing analgesia are more readily achieved once a chest tube has been removed. The result is superior patient outcomes with significantly fewer complications.

Chest tube-free video-assisted thoracoscopic surgery secured by quantitative air leak monitoring: a case series

Background

Although chest tube-omitted video-assisted thoracoscopic surgery (VATS) has been proven to be safe and efficacious, its universal application is precluded by a varying morbidity rate due to a lack of standardization. Since digital chest drainage has already shown improved accuracy and consistency in the management of postoperative air leak, we incorporated it in the strategy of intraoperative chest tube withdrawal, aiming to achieve better results.

Methods

We collected the clinical data of 114 consecutive patients who underwent elective uniportal VATS pulmonary wedge resection at the Shanghai Pulmonary Hospital from May 2021 to February 2022. Their chest tubes were withdrawn intraoperatively after an air-tightness test facilitated by digital drainage: the end flow rate had to be kept ≤30 mL/min for >15 s at the setting of -8 cmH₂O suctioning. The recordings and patterns of the air suctioning process were documented and analyzed as potential standards of chest tube withdrawal.

Results

The mean age of the patients was 49.7±11.7 years. The mean size of the nodules was 1.0±0.2 cm. The location of the nodules encompassed all lobes, and 90 (78.9%) patients received preoperative localization. The postoperative morbidity and mortality rates were 7.0% and 0%, respectively. Six patients had clinically overt pneumothorax and two patients had postoperative bleeding that required intervention. All of the patients recovered on conservative treatment except for one case of pneumothorax that required additional tube thoracostomy. The median length of postoperative stay was 2 days; and the median time of suctioning, peak flow rate, and end flow rate were 126 s, 210 mL/min, and 0 mL/min, respectively. The median numeric rating scale for pain was 1 on postoperative day (POD) 1 and 0 on the day of discharge.

Conclusions

Chest tube-free VATS assisted by digital drainage is feasible with minimal morbidity. Its strength of quantitative air leak monitoring produces important measurements for the prediction of postoperative pneumothorax and future standardization of the procedure.

Acute pain management after thoracoscopic lung resection: a systematic review and explorative meta-analysis

OBJECTIVES

Pain after thoracoscopic surgery may increase the incidence of postoperative complications and impair recovery. Guidelines lack consensus regarding postoperative analgesia. We performed a systematic review and meta-analysis to determine the mean pain scores of different analgesic techniques (thoracic epidural analgesia, continuous or single-shot unilateral regional analgesia and only systemic analgesia) after thoracoscopic anatomical lung resection.

METHODS

Medline, Embase and Cochrane databases were searched until 1 October 2022. Patients undergoing at least >70% anatomical resections through thoracoscopy reporting postoperative pain scores were included. Due to a high inter-study variability an explorative meta-analysis next to an analytic meta-analysis was performed. The quality of evidence has been evaluated using the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

A total of 51 studies comprising 5573 patients were included. Mean 24, 48 and 72 h pain scores with 95% confidence interval on a 0-10 scale were calculated. Length of hospital stay, postoperative nausea and vomiting, additional opioids and the use of rescue analgesia were analysed as secondary outcomes. A common-effect size was estimated with an extreme high heterogeneity for which pooling of the studies was not appropriate. An exploratory meta-analysis demonstrated acceptable mean pain scores of Numeric Rating Scale <4 for all analgesic techniques.

CONCLUSIONS

This extensive literature review and attempt to pool mean pain scores for meta-analysis demonstrates that unilateral regional analgesia is gaining popularity over thoracic epidural analgesia in thoracoscopic anatomical lung resection, despite great heterogeneity and limitations of current studies precluding such recommendations.

PROSPERO REGISTRATION

ID number 205311.

Uniportal video-assisted thoracoscopic surgery without drainage-tube placement for pulmonary wedge resection: a single-center retrospective study

BACKGROUND

Uniportal video-assisted thoracoscopic surgery without drainage-tube placement has been demonstrated to be safe and feasible for select situations. The purpose of this study is to assess the demographic, baseline, and intraoperative characteristics of patients who developed residual pneumothorax after thoracic surgery without drainage-tube placement.

METHODS

We reviewed the records of all patients who underwent pulmonary wedge resection via uniportal video-assisted thoracoscopic surgery without drainage-tube placement between May 2019 and May 2022. The decision to omit chest-tube drainage was originally made on a case-by-case basis, using internal criteria. Postoperative chest radiography was performed on the day of surgery, on postoperative day 1, at the first outpatient visit, and at 1 month after surgery.

RESULTS

A total of 134 patients met the selection criteria; 23 (17.2%) had residual pneumothorax on chest radiography on postoperative day 1, and 5 (3.7%) had residual pneumothorax at the first outpatient visit. Only 1 patient (0.7%) had residual pneumothorax on chest radiography at 1 month after surgery; this patient did not require chest-tube insertion or any other intervention. The presence of partial pleural adhesions independently increased the risk for postoperative residual pneumothorax on chest radiography, whereas older patient age reduced the risk.

CONCLUSIONS

Uniportal video-assisted thoracoscopic surgery for pulmonary wedge resection without drainage-tube placement is both safe and feasible for carefully selected patients. Most patients with residual pneumothorax in our study experienced spontaneous resolution, and none required reintervention.

No-drain management after thoracoscopic lung wedge resection with a novel intraoperative sealing test

OBJECTIVE

Although previous studies have reported the safety of no-drain management after thoracoscopic wedge resection, most of those studies were non-inferiority trials. The aim of this study was to evaluate whether no-drain management with an optimal sealing test affects post-operative complications in patients after thoracoscopic wedge resection.

METHODS

A total of 906 patients who underwent thoracoscopic lung wedge resection for various disorders except secondary pneumothorax between 2011 and 2020 were analyzed. According to intraoperative findings from the sealing test, patients were divided into groups with chest drain placement (Drain group, n = 514) or no-drain management (no-drain group, n = 392). Our intraoperative sealing test used a flexible drain (Blake^®, 19-Fr; Ethicon, Somerville, NJ) connected to the chest drain bag (- 10 cmH₂O) to monitor intrathoracic pressure and detect occult alveolar air leakage. Propensity score matching was conducted to balance baseline characteristics of the two groups and reduce selection bias.

RESULTS

A total of 250 pairs were matched and standardized differences suggested proper matching had been achieved. Mean length of post-operative hospital stay (4.6 days vs. 3.2 days, p < 0.001) was significantly lower in the no-drain group. Total post-operative complication rates were significantly lower in the no-drain group (6.4% vs. 2.4%, p = 0.03).

CONCLUSIONS

No-drain management after thoracoscopic wedge resection was associated with fewer post-operative complications and shorter hospital stay in selected patients. Our novel intraoperative sealing test may be useful for no-drain management of select patients.