Pleural drainage is essential for preventing and managing respiratory complications after video-assisted thoracoscopic esophagectomy (VATE). Conventional large-bore drains often cause significant pain. Small-bore drains (e.g., 19F Blake drains) may reduce discomfort; however, evidence regarding their use in VATE is limited. This study compared drainage effectiveness and pain between 19F Blake drains and conventional 28F drains after VATE for esophageal cancer. This retrospective study included 77 male patients with middle- or lower-third esophageal cancer who underwent VATE with laparoscopic retrosternal tunneling from November 2018 to November 2022. Fifty-five patients received a 28F conventional drain, and 22 received a 19F Blake drain. Outcomes included drainage duration and volume, pain levels (Visual Analog Scale [VAS]), postoperative pneumonia rates, and pulmonary function (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1]) on postoperative day 3. The 19F group reported significantly lower pain scores on postoperative days 1-3 (VAS: 2.95-3.25 vs. 4.07-4.62, p<0.001). Drainage duration and pneumonia rates were similar between groups. The 19F group demonstrated a trend toward higher drainage volume and significantly better preservation of pulmonary function, with smaller declines in FVC (ΔFVC: 0.24±0.20 L vs. 0.63±0.17 L, p<0.001) and FEV1 (ΔFEV1: 0.38±0.25 L vs. 0.58±0.25 L, p=0.02). 19F Blake drains provide similar drainage effectiveness to that of 28F drains, with reduced postoperative pain and better pulmonary function preservation. These findings support the use of 19F Blake drains to improve patient comfort and recovery following VATE.

Study objectives: We aimed to develop a drug-loaded hydrogel-encapsulated chest drain to improve postoperative comfort and recovery in thoracic surgery patients. Methods: The hydrogel was modified with different ratios of glycerol and alginate, then mixed with varying concentrations of ropivacaine and fixed on a simulated chest drain tube using a mould and calcium chloride solution. The morphology, degradation, and slow-release properties of the hydrogel were assessed to identify the most suitable formulation. A bacteriostatic test was conducted using bacterial smear plates. The new chest drain was then implanted in rats using the seldinger method. Pathological changes were observed with imaging techniques such as chest ultrasound and radiographs, while lung function was assessed to evaluate the analgesic effect. After the animal experiments, hematoxylin and eosin (H&E) and Masson staining were performed on relevant tissues to analyze inflammation, and SOD activity was measured to assess oxidative stress levels. Results: The optimal drug-loaded hydrogel for chest drains contained 2% sodium alginate, 10% glycerol, and ropivacaine concentrations between 0.25% and 0.75%. This formulation showed superior morphological characteristics, degradation, and sustained-release properties. It also exhibited excellent bacteriostatic effects. The low-concentration (0.25%) drug-loaded hydrogel demonstrated better analgesic, anti-inflammatory, and oxidative stress-inhibitory effects in animal studies. Conclusions: The modified ropivacaine-alginate hydrogel-encapsulated chest drain offers a promising local slow-release strategy and may contribute to rapid rehabilitation in thoracic surgery.

A Surprising Complication of Tube Thoracostomy: A Case of Persistent Hiccups.

Pleural infection results from bacterial entry and replication in the pleural space. Patients with pleural infection are a challenging subset, where appropriate antibiotic therapy, tube thoracostomy drainage, intrapleural enzymatic therapy (IET), and surgery are cornerstones of management. The factors influencing IET success remain unclear. A retrospective analysis of patients who received IET for pleural infection in our health system was conducted to identify factors associated with treatment outcomes. The electronic health record was queried for dispense and administration of intrapleural tPA and DNase between January 2018 and May 2024. Patients were included if they were over 18 years old with complicated parapneumonic effusion/empyema, had a CT chest within 1 day before thoracostomy tube insertion, received IET and had a follow-up CT chest within 7 days after the last IET dose. Volumetric analysis was performed for all patients. The clinical outcome was treatment success (clinical and radiologic improvement without need for surgical intervention). Of 185 patients included in the final analysis, 57 patients had treatment failure. The mean age was 56.8 years and were predominantly males. Pleural fluid biochemistry showed median pH and LDH were 7.00 and 1129U/L. Streptococcus species was the most common microbe in pleural cultures. Multivariable logistic regression analysis showed that a community source of infection was associated with treatment success, while a hospital source of infection was associated with a 71% risk of treatment failure [OR: 0.287 (95% CI: 0.115, 0.690); P = 0.006]. A community source of infection predicted treatment success with IET in our cohort.

New insights into the management of complicated pneumonia in children: A systematic review of randomized controlled trials.

Robotic-assisted bronchoscopy (RAB) is used to evaluate pulmonary nodules, particularly in populations at high risk for lung cancer. While its diagnostic utility and procedural safety have been established, limited data exist on the characteristics of patients, particularly Veterans, who undergo RAB in real-world clinical settings. This research examines the demographic, clinical, and procedural characteristics of Veterans who underwent RAB. We conducted a retrospective review of Veterans who underwent RAB. Descriptive statistics and exploratory analyses were used to identify patterns in patient characteristics, procedural utilization, patient outcomes, and treatment directions. Geospatial modeling was used to determine the distance traveled for procedures. Veterans were mostly male (aged: 71.73y) of which 66.6% had a smoking background. Patients were referred due to lung cancer screening (48.80%), incidental nodule finding (28.3%) or abnormal cancer surveillance (21.8%). Patients travelled 59.9 (2.7 to 841.4) miles to our facility. The median nodule size was 16mm (5 to 86mm) for primary nodules and 11mm (4 to 50mm) for secondary nodules. Complications occurred in 4.8% of cases with pneumothorax requiring chest tube being the most common (2.2% of cases). Diagnostic yield based upon strict criteria was 86.3%, with an additional 12.6% patients with radiologically followed scarring/fibrosis. On average, patients who had received a diagnosis using RAB waited around 2 months for their first treatment. This study provides an overview of RAB in a Veteran population. Understanding these characteristics will help to refine procedural workflows, contribute to broader efforts to personalize diagnostic strategies, and optimize treatment pathways for Veterans.

Effectiveness of Rapid Cycle Deliberate Practice (RCDP) on Technical and Non-Technical Skills in Chest Tube Insertion and Fixation: A Pilot Study.

Cognitive Load Effect on Intraoperative Learning - A Randomized Trial in Simulation-Based Settings.

Efficacy of autologous blood patch injection for the prevention of pneumothorax after transthoracic lung biopsy.

Honing the Cutting Edge of Physician Assistant Surgical Education in the US Military: A Curriculum Update Using Kern's Approach and a Modified Delphi Method.

Single-Center Experience with Sonic Estimation of Elasticity via Resonance (SEER)-Guided Hemostasis in Adult Cardiac Surgical Patients.

Cold-stored platelets: A systematic review of recovery in healthy adults and chest drain output in cardiothoracic surgery patients.

Introduction. Spontaneous pneumothorax in men is a clinically relevant condition with recurrence rates up to 30% after the first episode. Advances in thoracic surgery have shifted management from conservative observation to minimally invasive strategies prioritizing functional preservation. Non-intubated uniportal video-assisted thoracoscopic surgery combined with Enhanced Recovery After Surgery protocols is considered a promising option, though evidence on long-term outcomes remains limited. Aim. To assess the feasibility, safety, and long-term results of non-intubated uniportal video-assisted thoracoscopic surgery performed within Enhanced Recovery After Surgery protocols in men with spontaneous pneumothorax. Materials and methods. A retrospective analysis of 80 men treated between 2017 and 2023 was conducted. Data included demographics, operative time, blood loss, anesthesia safety, postoperative pain, chest drainage duration, hospital stay, complications, and recurrence. All procedures were performed under thoracic epidural anesthesia with multimodal pain management. Follow-up averaged 60 months. Results. All surgeries were completed without conversion to thoracotomy. The mean operative time was 67 minutes, and blood loss was minimal. Physiological stability was preserved, with no anesthesia-related complications. Pain intensity was low (mean visual analogue scale 1.9), oral intake resumed within 1 hour, and mobilization within 2–3 hours. Chest drainage lasted a mean of 3.3 days. Complications were rare, with prolonged air leak in 10% of cases. Recurrence was documented in 5% during long-term follow-up, all successfully managed with repeat minimally invasive surgery. Conclusions. Non-intubated uniportal video-assisted thoracoscopic surgery within Enhanced Recovery After Surgery protocols is a safe and effective strategy for men with spontaneous pneumothorax. It minimizes perioperative trauma, accelerates functional recovery, reduces opioid use, and provides durable control of recurrence. Larger multicenter trials are required to confirm these findings and refine patient selection criteria.

To investigate the key points in performing thoracoscopic anatomic pulmonary lesion resection procedures, as well as analyze the characteristics of the learning curve associated with the surgery.We retrospectively collected clinical data and 1-year follow-up outcomes of children diagnosed with congenital pulmonary airway malformation (CPAM) who underwent thoracoscopic anatomic lesion resection in our hospital from January 2019 to December 2023. Perioperative and short-term follow-up results were analyzed and surgical experiences and insights were summarized. Furthermore, the cumulative sum (CUSUM) method was employed to plot the learning curve of a single surgeon performing thoracoscopic anatomic resection, and the impact of different phases on perioperative parameters and early follow-up outcomes was investigated.This study included 154 patients undergoing thoracoscopic anatomic lesion resection. Postoperative complications occurred in three patients (1.9%), and residual lesions were identified in four cases (2.6%). When a single surgeon's procedural volume exceeded 39 cases, marking the transition to the proficiency phase, significant reductions were observed in operative time, intraoperative blood loss, postoperative hospital stay, and postoperative mechanical ventilation duration compared with the learning phase (all p < 0.05). No significant differences were found in postoperative drainage volume and chest tube duration.The key to thoracoscopic anatomic lesion resection lies in identifying the lesion boundaries and achieving precise dissection. Our study showed that this surgical approach is relatively safe and feasible for children with CPAM, with favorable perioperative and 1-year postoperative outcomes. Moreover, as surgeons progress to proficiency, perioperative outcomes improve and the incidence of residual lesions decreases. However, as a single-center study with a limited number of cases and due to a lack of long-term follow-up data, the safety and efficacy of this technique still require further validation through multi-center studies.

Background: Prolonged air leak (PAL) remains one of the most frequent and challenging complications after anatomical lung resection. PAL is associated with longer chest tube duration, increased postoperative complications, delayed discharge, and higher costs. Although various strategies—including digital chest drainage systems, low suction protocols, pleurodesis, sealants, and phrenic nerve cryoneuroablation—have been introduced, their benefits have not been consistently defined. Our objective is to evaluate the effect of different preventive and management interventions on the incidence of PAL, chest tube duration, and hospital stay following anatomical lung resection. Methods: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of randomized and observational studies that assessed strategies to prevent or reduce PAL after anatomical lung resection. Outcomes included PAL incidence, chest tube duration, and hospital length of stay. Pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using fixed- or random-effects models depending on heterogeneity. Results: Eight RCT studies including over 1,000 patients met the eligibility criteria. Pooled analysis demonstrated that these interventions significantly reduced the risk of PAL compared with standard care (OR = 0.45, 95% CI 0.28–0.72, p = 0.0009; I²= 14%). The interventions were also associated with a marked reduction in chest tube duration (MD = –1.12 days, 95% CI –1.19 to –1.06, p &lt; 0.00001; I² = 94%) and a shorter hospital stay (MD = –0.59 days, 95% CI –0.87 to –0.31, p &lt; 0.0001; I² = 66%). Conclusion: Interventions such as digital drainage systems, low suction protocols, pleurodesis, sealants, and phrenic nerve cryoneuroablation reduce PAL incidence and expedite recovery after anatomical lung resection. Their integration into standardized perioperative pathways can improve outcomes and resource utilization. Further multicenter studies are needed to confirm these findings and define optimal protocols.

Background Elderly patients undergoing lung resection are particularly susceptible to postoperative adverse respiratory events (AREs), due to age-related physiological decline and a higher incidence of residual neuromuscular blockade (RNMB). Sugammadex is a selective relaxant binding agent that enables rapid and complete reversal of aminosteroid neuromuscular blocking agents such as rocuronium, offering potential advantages over traditional acetylcholinesterase inhibitors like neostigmine. However, evidence directly comparing the impact of sugammadex versus neostigmine on clinically relevant respiratory outcomes, particularly AREs in elderly patients undergoing lung resection remains limited. Methods and analysis This is a prospective, double-blinded, randomized controlled clinical trial involving 530 elderly patients (≥65 years old) scheduled for video-assisted thoracoscopic lung surgery requiring one-lung ventilation. Patients will be 1:1 randomized to receive sugammadex or neostigmine for neuromuscular blockade reversal. The primary outcome is a composite of AREs occurring in the post-anaesthesia care unit (PACU). Secondary outcomes include time from neuromuscular to extubation, the composite of ARE and rescue measures, PACU length of stay, postoperative pulmonary and extra-pulmonary complications, unplanned intensive care unit (ICU) admission, chest drainage tube duration, hospital length of stay, and mortality. All patients will be followed up until 30 days after surgery. The primary analysis will be conducted on a modified intention-to-treat basis. Discussion This trial is designed to address a critical gap in perioperative care for elderly patients undergoing lung resection by directly comparing sugammadex and neostigmine in terms of clinically meaningful respiratory outcomes. While previous studies have primarily focused on pharmacokinetic profiles or surrogate markers such as train-of-four recovery time, evidence regarding the impact of these agents on postoperative AREs remains limited. Given the growing elderly surgical population and the high incidence of RNMB and pulmonary complications in this group, the findings of this study will offer valuable insight into optimizing neuromuscular blockade reversal strategies. Trial registration This study is registered at Chinese clinical trial registry (ChiCTR2400094005).

Abstract Aim Medical waste contributes 5–10% of plastic waste. Chest drain (CD) bottles are single-use items, typically changed daily, exacerbating this problem. Each CD bottle in our unit generates 2.53 kg of CO₂e (production, transport, disposal). With simple nursing education, we changed the protocol from daily CD bottle changes to changing only when the bottle is full (1800 ml) or when drainage colour changes. Method This QI project included a retrospective (July 2023–October 2023) analysis of post-ILGO patients. Patients with abandoned procedures or CD bottle changes in ITU were excluded. Post-intervention, a prospective analysis (December 2023–April 2024) was undertaken. Data included length of stay, total CD bottles, carbon emissions, and financial savings. Results 20 patients were included in each cycle. First cycle, 185 CD bottles (median 7) were used during a median stay of 7 days, generating 468.93 kg of CO₂e and costing £1,424.50. Post-intervention, 47 CD bottles (median 2) were used during a median stay of 8 days, generating 119.13 kg of CO₂e and costing £361.90. This represented a 74.6% reduction in cost and carbon emissions. No complications related to extended CD bottle use were recorded. By reducing the frequency of bottle changes, this practice offered undocumented financial savings through reduced nursing time and risk of complications from human errors, such as CD malposition, clamped CD, or missed water seal. Conclusions Extended CD bottle use post-ILGO is safe, cost-effective, and supports NHS sustainability goals. Our unit now saves 11.11 kg CO₂e and £38.50 per post-ILGO patient.

BackgroundThe standard surgical treatment for early-stage non-small cell lung cancer (NSCLC) involves anatomical lobectomy and mediastinal lymph node dissection (MLND). According to the principle of “from distal to proximal” during tumour resection, MLND should ideally be performed before lobectomy to fit the criteria of surgical oncology. However, no prospective randomised controlled trial (RCT) has compared MLND-first versus lobectomy-first approaches in early-stage NSCLC. This provides the rationale for this multicentre RCT.MethodsThis multicentre, prospective, open-label, RCT investigates the superiority of MLND-first over lobectomy-first in terms of long-term survival in patients with clinical stage T1-2N0-1M0 (stages I–II) NSCLC (LOFTY study). We plan to enrol 620 patients from multiple institutions. Stratified block randomisation will be performed in this trial. The primary endpoint is the 5-year disease-free survival rate, and the secondary endpoints comprise the 5-year overall survival rate and short-term outcomes, such as conversion rate, perioperative complication rate, number of resected mediastinal lymph nodes, operative death rate, postoperative hospital stays, R0 rate, operative time, chest tube duration, number of circulating tumour cells before and after operation, and the total cost of hospitalisation. The primary endpoint will be assessed by a central committee of blinded expert radiologists. Patient recruitment is currently ongoing.DiscussionThis multicentre, prospective, open-label RCT investigates whether MLND-first is superior to lobectomy-first in terms of long-term outcomes in early-stage NSCLC patients who are suitable for lobectomies. The results of this trial will provide high-level evidence to clarify the standard surgical sequence for early-stage operable NSCLC.Trial registrationGuangdong Association Study of Thoracic Oncology GASTO-10129. Registered on 26 March. 2022. Chinese Clinical Trials Registry ChiCTR2300068586. Registered on 24 February 2023. ClinicalTrial.gov NCT06577792. Registered on 29 August 2024.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13063-025-09285-9.

Abstract Introduction Boerhaave’s syndrome is a rare but potentially life-threatening rupture of the oesophagus. Despite advances in diagnosis and management, it still has a high mortality rate. While single episodes of Boerhaave’s syndrome are uncommon, recurrent spontaneous oesophageal perforations are exceedingly rare. Case Presentation This is a case of a 45-year-old gentleman, presenting with Boerhaave’s syndrome 3 times, over 26 months. He initially presented in April 2023 and was managed with a thoracotomy and primary repair of the oesophagus over a T-tube which failed. An attempt at disconnection was undertaken but abandoned due to a hostile chest and the patient was subsequently managed with endovac therapy. Second presentation was October 2024. He was initially managed with endovac therapy but due to the chronic chest cavity poor progress was made. A covered oesophageal stent was utilised alongside chest drainage. In April 2025, he was re-admitted with a further episode. Again, he was managed with endovac therapy and Vac Stent placement. His most recent admission has been complicated by poor functional status, ongoing respiratory issues and he has been discharged to his base hospital for prolonged tracheostomy weaning. Discussion Recurrent Boerhaave’s syndrome challenges the traditional assumption that a successfully treated oesophageal rupture is a one-time event. While the management in the repeated episodes does not necessarily differ substantially, what becomes more nuanced is the decision-making surrounding treatment. Particularly in this case, where each time the patient is in a much poorer physiological state, making the decision making even more complex.

Background: Trauma care across Vancouver Island is delivered at two trauma centers which serves a population of 864,000. As part of program planning and delivery we routinely monitor Patient Safety Learning System (PSLS) reports, survey staff, and conduct case (MTPRC) reviews. Using these mechanisms, we identified the need to standardize care practices, improve staff training, and simplify the management of thoracostomy tubes. Our intervention introduced a digital chest drainage system to replace the gravity drainage system. Methods: We used a mixed-methods approach to identify practice issues and design and analyse quality improvement (QI) efforts. We analyzed open and directed staff surveys, text parsed bulk PSLS reports, and manual selected MTPRC cases. PSLS and MTPRC responses were coded thematically using conventional content analysis. Staff satisfaction with the QI work was assessed using Wilcoxon signed-ranks testing. Ongoing longitudinal assessment of the QI intervention will be used to describe the clinical impact of the QI intervention. Results Surveys identified that most nurses, 57.5% (n=40), wanted chest tube training. The least understood aspects of care were assessing air leaks, tidalling and excess negativity; and changing the collection canisters. We screened PSLS reports between 2022 and 2024 (n=4300), limited them by catchment area (n=1945), text-parsed them as chest-tube related (n=116), then manually screened them to identify 11 trauma-related chest tube events. Coding of PSLS (n=11) and MTPRC cases (n=14) identified two causal themes: i) management inconsistency (in physician ordering and clinical governance) and, ii) devices issues (chest tubes, securement, collection canisters and space). These cases resulted in delayed care (including prolonged stay) in three cases, unnecessary tube (re)placement (n=12), and clinical deterioration (n=3). Our QI initiative implemented a digital drainage system. Digital systems automatically modulate thoracic negativity, digitally display air-fluid leaks and tidalling, and provide audio-visual alarms and prompts to address pump and collection canister issues. Orientation sessions trained 76.5% of staff. Postimplementation surveys (n=18) showed 61.1% or respondents had used the digital system. Most rated the digital system as safer (z=3.67, r=0.61, p&lt;0.01), easier (z=3.66, r=0.61, p&lt;0.01), superior (z=3.78, r=0.63, p&lt;0.01), and preferable (z=3.87, r=0.64, p&lt;0.01) to gravity drainage. The response was not attributable to difference in the perceived level of training (z=1.41, p=0.16). Ongoing analysis on the clinical effect of the system will be available by the time of the conference. Implications and lessons learned We used small-scale surveys to assess staff, large-scale PSLS surveillance to identify rare safety events, and a mixed-methods approach to identify opportunities for QI. We used digital chest drainage system to address the most cited challenges in chest tube care. As a result, we have seen an increase in staff perceptions of patient safety and ease of care. Ongoing analyses will determine if this initiative is correlated with changes in patient outcomes and safety events.