Early Chest Tube Removal Research Articles

Postoperative day 1 discharge following subxiphoid thoracoscopic anatomical lung resection: a single-centre, postoperative enhanced recovery experience.

The goal of this study was to assess the safety and quality of recovery (QOR) after discharge on postoperative day (POD) 1 following subxiphoid thoracoscopic anatomical lung resection within an advanced Enhanced Recovery After Surgery (ERAS) program. A retrospective analysis of prospectively collected data was conducted. Characteristics, perioperative and outcome data, compliance with ERAS pathways and a home-transition QOR survey were analysed using a multivariable logistic regression model. From January 2020 to January 2022, a total of 201 consecutive patients underwent subxiphoid multiportal thoracoscopic anatomical lung resection, comprising 108 lobectomies and 93 sublobar resections (SLRs) (59 complex SLRs and 34 simple SLRs). Among them, 113 patients (56%) were discharged on POD 1, 49% after a lobectomy, 59% after a simple sublobar resection and 68% after a complex sublobar resection. In the multivariable analysis, age > 74 years and duration of the operation were associated with discharge after POD 1, whereas forced expiratory volume in 1 s and complex SLRs were associated with discharge on POD 1. Chest tube removal was achieved on POD 0 in 58 patients (29%), and 138 patients (69%) were free from a chest tube on POD 1. There were 13% with in-hospital morbidity, 10% with 90-day readmission (7% after POD 1 discharge and 14% in patients discharged after POD 1), and 0.5% with 90-day mortality. Patients discharged on POD 1 showed better compliance with the ERAS pathway with early chest tube removal and opioid-free analgesia. The home-transition QOR survey reported a better experience of returning home after discharge on POD 1 and similar pain scores. Postoperative day 1 discharge can be safely achieved in appropriately selected patients after subxiphoid thoracoscopic anatomical lung resection, with excellent outcomes and high quality of recovery, supported by early chest tube removal as a determinant ERAS pathway.

Lessons from short chest drain management for primary spontaneous pneumothorax.

Video-assisted thoracic surgery (VATS) bullectomy is the mainstay treatment for primary spontaneous pneumothorax (PSP) but we encounter patients with pain due to chest tube. This study investigated the postoperative outcomes of shortened silicone drain as a chest tube after VATS bullectomy to reduce pain. The current study included patients aged < 30years who underwent VATS bullectomy for PSP. Patients with normal intrathoracic lengths of the silicone drain placed in a loop at the apex toward the diaphragm were categorized as Group L, whereas those with the silicone drain shortened to approximately 10cm and placed toward the apex were classified as Group S. Postoperative pain evaluated using a numerical rating scale (NRS) and other perioperative outcomes were compared between the groups. Altogether, 43 patients were included, with 22 in Group L and 21 in Group S, respectively. The NRS before chest tube removal was significantly lower in Group S (mean, 2.1) than in Group L (4.4; p = 0.001). In Group L, 4 patients (p = 0.017) required early chest tube removal than expected due to severe pain whereas none in Group S required this intervention; additionally, more patients needed additional analgesics than in Group S (p = 0.003). In VATS bullectomy for PSP, the pain intensity could be reduced by shortening the intrathoracic length of the silicone drain, compared to a longer intrathoracic length of the silicon drain. Our findings contribute to the establishment of optimal postoperative management of general thoracic surgery.

Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Following Neoadjuvant Immunochemotherapy in Resectable Stage III Non-Small Cell Lung Cancer Among Chinese Populations: A Multi-Center Retrospective Cohort Study

BackgroundImmune checkpoint inhibitors have revolutionized non-small cell lung cancer (NSCLC) treatment but may pose greater technical challenges for surgery. This study aims to assess the feasibility and oncological effectiveness of video-assisted thoracoscopic surgery (VATS) for resectable stage III NSCLC after neoadjuvant immunochemotherapy. MethodsInitial stage IIIA-IIIB NSCLC patients with neoadjuvant immunochemotherapy undergoing either VATS or open lobectomy at 6 medical centers during 2019-2023 were retrospectively identified. Perioperative outcomes and 2-year survival was analyzed. Propensity-score matching (PSM) was employed to balance patient baseline characteristics. ResultsAmong the total 143 patients, PSM yielded 62 cases each for VATS and OPEN groups. Induction-related adverse events were comparable between the 2 groups. VATS showed a 14.5% conversion rate. Notably, VATS decreased numeric rating scales for postoperative pain, shortened chest tube duration (5[4-7] vs. 6[5-8] days, P = .021), reduced postoperative comorbidities (21.0% vs. 37.1%, P = .048), and dissected less N1 lymph nodes (5[4-6] vs. 7[5-9], P = .005) compared with thoracotomy. Even when converted, VATS achieves perioperative outcomes equivalent to thoracotomy. Additionally, over a median follow-up of 29.5 months, VATS and thoracotomy demonstrated comparable 2-year recurrence-free survival (77.20% vs. 73.73%, P = .640), overall survival (87.22% vs. 88.00%, P = .738), cumulative incidences of cancer-related death, and recurrence patterns. Subsequent subgroup comparisons and multivariate Cox analysis likewise revealed no statistical difference between VATS and thoracotomy. ConclusionVATS is a viable and effective option for resectable stage III NSCLC patients following neoadjuvant immunochemotherapy, leading to decreased surgical-related pain, earlier chest tube removal, reduced postoperative complications, and similar survival outcomes compared to thoracotomy.

Protocol for a randomised controlled trial: optimisation of perioperative analgesia protocol for uniportal video-assisted thoracoscopic surgery

IntroductionPostoperative pain after thoracic surgery impairs patients’ quality of life and increases the incidence of respiratory complications. Optimised analgesia strategies include minimally invasive incisions, regional analgesia and early chest tube...

Early chest tube removal on the 1st postoperative day protocol of an enhanced recovery after cardiac surgery programme is safe.

The aim of this study was to assess the safety of early chest tube removal (CTR) protocol on the 1st postoperative day (POD1) of our Enhanced Recovery After Surgery (ERAS) programme by comparing the risk of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. All consecutive patients undergoing elective coronary revascularization and/or valve surgery between 2015 and 2021 were assessed in terms of their perioperative management pathways: conventional standard of care (control group) versus standardized systematic perioperative ERAS programme including an early CTR on POD1 (ERAS group). A propensity score matching was applied. The primary end-point was a composite of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. A total of 3153 patients were included. Propensity score analysis resulted in 2 groups well-matched pairs of 1026 patients. CTR on POD1 was significantly increased from 29.5% in the control group to 70.3% in the ERAS group (P < 0.001). The incidence of the primary end-point was 6.4% in the control group and 6.9% in the ERAS group (P = 0.658). Patients in the ERAS group, as compared with control group, had significant lower incidence of bronchopneumonia (9.0% vs 13.5%; P = 0.001) and higher incidence of mechanical ventilation ≤6 h (84.6% vs 65.2%; P < 0.001), length of intensive care unit ≤1 day (61.2% vs 50.8%; P < 0.001) and hospital ≤6 days (67.3% vs.43.2%; P < 0.001). CTR on POD1 protocol can be safely incorporated into a standardized systematic ERAS programme, enabling early mobilization, and contributing to the improvement of postoperative outcomes. Ethics committee of the French Society of Thoracic and Cardio-Vascular Surgery (CERC-SFCTCV-2022-09-13_23140).

Timing of Chest Tube Removal Following Adult Cardiac Surgery: A Cluster Randomized Controlled Trial

Objectives Early chest tube removal following cardiac surgery may be associated with an increased risk of pleural or pericardial effusions following cardiac surgery. This study compares the effects of two fast-track chest tube removal protocols regarding the risk of pleural or pericardial effusions, requirement of opioids, respiratory function, and postoperative complications. Design Prospective non-blinded cluster-randomized study with alternating chest tube removal protocol in adult patients undergoing elective cardiac surgery. Monthly changing allocation to scheduled chest tube removal on the day of surgery (Day 0) versus removal on the 1st postoperative day (Day 1) provided no air leakage and output < 200 mL within the last four hours. Results A total of 527 patients were included in the study from September 1st 2020 until October 29th 2021 and randomly allocated to chest tube removal at day 0 (n = 255), and day 1 (n = 272). More than every fourth patient required drainage for pleural effusion with no significant difference between the groups. Earlier removal of chest tubes did not reduce requirement of analgesics, improve early respiratory function, or reduce postoperative complications. The study was halted for futility after halfway interim analysis showed insufficient promise of any treatment benefit. Conclusion Fast-track protocols with chest tube removal within the first 24 h after cardiac surgery may be associated a high rate of pleural effusions.

Analgesic Effectiveness of Dinalbuphine Sebacate in Video-Assisted Thoracoscopic Wedge Resection and Its Effect on Reducing Postoperative Pulmonary Complications: A Retrospective Cohort Study.

Inadequate postoperative analgesia may cause postoperative complications, such as pulmonary complications. This study evaluated the analgesic effectiveness of a single preoperative injection of dinalbuphine sebacate (DS) in patients undergoing video-assisted thoracoscopic wedge resection and assessed whether it can reduce the incidence of postoperative pulmonary complications (PPCs). In this study, the data of 757 patients who underwent VATS wedge resection at a medical center were retrospectively reviewed. The patients were divided into the DS group and the conventional analgesia (CA) group. The following parameters were analyzed: analgesic consumption during hospitalization, the incidence of PPCs, and the postoperative use of oxygen therapy. Compared with the CA group, the DS group had lower nalbuphine, tramadol, parecoxib, acetaminophen, diclofenac, and utraphen consumption during the postoperative period; higher morphine and ketorolac consumption; and comparable fentanyl consumption. Nonetheless, the frequency of requesting pain relief was significantly lower in the DS group. No significant between-group differences were noted in the incidence of PPCs. However, the DS group had fewer requirements for oxygen therapy in the ward, early removal of chest tubes, and shorter length of hospital stay. A single preoperative injection of DS reduced the frequency of salvage analgesic administration and total consumption of certain postoperative analgesics, suggesting the effective pain relief of DS, and it did not increase the incidence of PPCs. Additionally, it reduced the need for postoperative oxygen therapy, which may suggest a better prognosis and smoother postoperative pulmonary recovery for patients.

Early chest tube removal regardless of drainage volume after anatomic pulmonary resection: A multicenter, randomized, controlled trial

ObjectivesThis study aimed to evaluate the safety and feasibility of early chest tube removal after anatomic pulmonary resection, regardless of the drainage volume. MethodsWe conducted a multicenter, randomized, controlled, noninferiority trial. Patients with greater than 300 mL drainage volume during postoperative day 1 were randomly assigned to group A (tube removed on postoperative day 2) and group B (tube retained until drainage volume ≤300 mL/24 hours). The primary end point was the frequency of respiratory-related adverse events (grade 2 or higher based on the Clavien–Dindo classification) within 30 days postoperatively. ResultsBetween April 2019 and October 2021, 175 patients were assigned to group A (N = 88) or group B (N = 87). One patient in group B who experienced chylothorax was excluded from the study. Respiratory-related adverse events were observed in 10 patients (11.4%) in group A and 12 patients (14.0%) in group B (P = .008). The frequencies of thoracentesis or chest tube reinsertion were not significantly different (8.0% and 9.3% in groups A and B, respectively, P = .752). Additionally, the duration of chest tube placement was significantly shorter in group A than in group B (median, 2 vs 3 days; P < .001). No significant difference between groups A and B was found in postoperative hospital stay (median, 6 vs 7 days, P = .231). ConclusionsEarly chest tube removal, regardless of drainage volume, was safe and feasible in patients who underwent anatomic pulmonary resection.

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

ObjectiveChest tubes cause pain and morbidity. MethodsThis 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. ResultsBetween 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. ConclusionsChest 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.

Perioperative outcomes of robotic-assisted versus video-assisted thoracoscopic lobectomy: A propensity score matched analysis.

The existing literature on perioperative outcomes of robotic-assisted thoracoscopic surgery (RATS) versus video-assisted thoracoscopic surgery (VATS) for lung lobectomy is inconclusive. We conducted a retrospective cohort analysis of VATS and RATS lobectomy procedures for patients with non-small cell lung cancer to compare the short-term perioperative outcomes by propensity score matching (PSM) analysis. A total of 418 patients were enrolled in this study. After PSM, 71 patients each received VATS and RATS lobectomy for further analysis. RATS lobectomy was associated with a lower rate of conversion to thoracotomy (0% vs. 5.63%, p = 0.006), a lower rate of postoperative prolonged air leak (1.14% vs. 19.72%, p = 0.001) and a shorter duration of postoperative chest tube drainage (3 days interquartile range [IQR: 3, 4] vs. 4 days IQR [3-5], p = 0.027). Subgroup analysis indicated that after acquiring proficiency in the RATS procedure, its disadvantages diminished while its advantages were enhanced. In terms of rate of conversion to thoracotomy, length of hospital stays, and duration of postoperative chest tube drainage, RATS was comparable to uniportal VATS and superior to triportal VATS. RATS has advantages over VATS in terms of early chest tube removal, early discharge, lower thoracotomy rate, less postoperative air leak, and a potential trend of more lymph node dissection numbers. These advantages are more pronounced after acquiring proficiency in RATS.

Early ambulation and postoperative recovery of patients with lung cancer under thoracoscopic surgery—an observational study

BackgroundEnhanced recovery after surgery guidelines in China recommend early ambulation within 24 h after surgery. The aims of this audit were to investigate the early ambulation of patients with lung cancer under thoracoscopic surgery, and to explore the influence of different ambulation time on postoperative rehabilitation of patients.MethodsUsing observational study method, observe and record of 226 cases under the thoracoscope surgery early ambulation of patients with lung cancer. Data collected included postoperative bowel movements, chest tube extubation time, length of hospital stay, postoperative pain and the incidence of postoperative complications.ResultsThe time of first ambulation was (34.18 ± 17.18) h, the duration was (8.26 ± 4.62) min, and the distance was (54.94 ± 46.06) m. The time of first postoperative defecation, the time of chest tube extubation and the length of hospital stay were significantly shortened in patients who ambulate within 24 h, and the pain score on the third day after surgery was decreased, and the incidence of postoperative complications was reduced, with statistical significance (P < 0.05).ConclusionEarly ambulation within 24 h after thoracoscopic surgery for lung cancer patients can promote the recovery of intestinal function, early removal of chest tube, shorten the length of hospital stay, relieve pain, reduce the incidence of complications, and facilitate the rapid recovery of patients.

Efficacy and safety of early chest tube removal after selective pulmonary resection with high-output drainage: A systematic review and meta-analysis.

There is controversy over the drainage threshold for removal of chest tubes in the absence of significant air leakage after selective pulmonary resection. A comprehensive search of online databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, Ovid, Elsevier, Ebsco, and Wiley) and clinical trial registries (WHO-ICTRP and ClinicalTrials.gov) was performed to investigate the efficacy and safety of early chest tube removal with high-output drainage. Primary outcome (postoperative hospital day) and secondary outcomes (30-day complications, rate of thoracentesis, and chest tube placement) were extracted and synthesized. Subgroup analysis, meta-regression, and sensitivity analysis were used to explore the potential heterogeneity. Study quality was assessed with the Newcastle-Ottawa Scale, and evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment by the online GRADEpro Guideline Development Tool. Six cohort studies with a total of 1262 patients were included in the final analysis. The postoperative hospital stay in the high-output group was significantly shorter than in the conventional treatment group (weighted mean difference: -1.34 [-2.34 to -0.34] day, P = .009). While there was no significant difference between 2 groups in 30-day complications (relative ratio [RR]: 0.92 [0.77-1.11], P = .38), the rate of thoracentesis (RR: 1.93 [0.63-5.88], P = .25) and the rate of chest tube placement (RR: 1.00 [0.37-2.70], P = .99). According to the sensitivity analysis, the relative impacts of the 2 groups had already stabilized. Subgroup analysis revealed that postoperative hospital stay was modified by Newcastle-Ottawa Scale score. The online GRADEpro Guideline Development Tool presented very low quality of evidence for the available data. This meta-analysis revealed that it is feasible and safe to remove a chest tube with high-output drainage after pulmonary resection 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.

Early chest tube removal within 6 hours after thoracic surgery results in improved postoperative prognosis and no adverse effects.

Advances in minimally invasive surgery and drainage systems have caused earlier chest-tube-removal. This retrospective study aimed to assess the safety of early chest tube removal using the institution's new criteria 6 hours after thoracic surgery. Elective thoracic surgery patients from 2017 to 2023 were reviewed for meeting or not meeting the newer institutional requirement for early chest tube removal; (I) no air leak detected under the digital drainage device observation; (II) no fluid drainage of ≥100 mL/h; (III) no ≥3 combined risks [male, chronic obstructive pulmonary disease (COPD), body mass index (BMI) of <18.5 kg/m2, severe pleural adhesion, upper lobe lobectomy, or left upper division segmentectomy]. The incidence of adverse events, including chest tube replacement, subcutaneous tube placement, and postoperative thoracentesis, were investigated for 1 month postoperatively. Perioperative outcomes and factors involved in conventional chest tube removal were also assessed. Of the 942 patient charts reviewed, 244 (25.9%) met the criteria for chest tube removal within 6 hours postoperatively. This patient group did not experience adverse events. They also demonstrated shorter postoperative hospital stay (4 vs. 6 days, P<0.001), and lesser postoperative complications (7.4% vs. 25.6%, P<0.001) compared to those for whom early chest tube removal was not done. A correlation with thoracotomy, COPD, and steroid and/or immunosuppressant use was observed for patients in the conventional chest tube removal group. Early chest tube removal after 6 postoperative hours was deemed safe for a selected group of patients who met the criteria for early chest tube removal. This study would support the potential expansion of our early removal criteria.

Multidisciplinary Review Committee Oversight Improves Adherence to Newly Implemented Thoracic Enhanced Recovery after Surgery Protocol

INTRODUCTION: Benefits of thoracic Enhanced Recovery After Surgery (ERAS) programs have been well described in the literature. After implementing a thoracic ERAS program, we sought to determine if compliance review during quality improvement meetings improved protocol adherence. METHODS: A multidisciplinary committee developed and implemented a thoracic ERAS protocol for anatomic lung resections across 6 hospitals within our health system. Adherence data was tracked for 3 months after initiation of the ERAS protocol, a quality review committee meeting was held to review compliance barriers, and 2 additional months of compliance data were recorded. We examined compliance changes to 5 key protocol elements. Pathway elements deferred due to mindful deviation were excluded. Chi-square and Fisher’s exact tests were used to compare categorical data where appropriate. RESULTS: We included 81 patients, 53 patients before the quality review committee meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall adherence improved after the quality review committee meeting (Table; 53% vs 84%, p < 0.001). Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in post-anesthesia recovery unit, early chest tube removal, and postoperative multimodal pain regimen use improved after the quality review committee meeting (all p < 0.05). Use of preoperative pain bundles improved, but this did not reach statistical significance (87% vs 96%, p = 0.25). CONCLUSION: Conducting a thoracic ERAS quality review meeting to identify compliance barriers significantly improved protocol adherence. This experience can be extrapolated to other institutions implementing ERAS protocols. Table. - Adherence to Targeted Enhanced Recovery After Surgery (ERAS) Elements Before and after the First Quality Review Committee Meeting Adherence item Pre-meeting cohort adherence Post-meeting cohort adherence p Value Preoperative pain bundle given 45/52 (87%) 26/27 (96%) 0.25 Intraoperative indwelling urinary catheter avoided 5/33 (15%) 22/27 (81%) <0.001 Chest tube placed to water seal in PACU 4/29 (14%) 9/16 (56%) 0.005 Early chest tube removal 21/52 (40%) 15/21 (71%) 0.02 Use of opioid sparing multimodal pain regimen 39/52 (75%) 28/28 (100%) 0.002 Overall 114/218 (53%) 100/119 (84%) <0.001

Video-assisted thoracoscopic surgery and mini-thoracotomy compared to conventional thoracotomy in the surgical management of pulmonary hydatid cyst

Background: Although hydatid cyst disease is not common in western countries, it is a public health issue in the Middle East, including Iraq. We describe a new method in the surgical management of the disease. Aim of the study was to evaluate the outcomes of different surgical approaches: video-assisted thoracoscopic surgery (VATS), mini-thoracotomy, and conventional thoracotomy in managing pulmonary hydatid cysts.Methods: Retrospective analysis of the surgical treatment of pulmonary hydatid cysts between January 2017 and December 2021 in two centers. Patients' data regarding the age, sex, sign and symptoms, cyst size and location, surgical approach, operative time, the intraoperative bleeding, chest drainage, hospitalization time, and postoperative complications.Results: A total of 122 patients were included in the study; 9 underwent VATS, 59 underwent mini-thoracotomy, and 54 had conventional thoracotomy. The VATS and mini-thoracotomy has superiority to the thoracotomy group in terms of lower duration of operation, less perioperative bleeding, early chest tube removal, and lower hospitalization time.Conclusions: VATS and mini-thoracotomy are safe and advantageous procedures compared to conventional thoracotomy.

Enhanced Recovery Pathway in Lung Resection Surgery: Program Establishment and Results of a Cohort Study Encompassing 1243 Consecutive Patients

Simple SummaryEnhanced Recovery Pathways (ERP) have been scarcely assessed in lung cancer surgery. We performed a two-step audit for our experience: the first dealing with our initial experience focusing on patients undergoing segmentectomies and lobectomies, the second including all subsequent consecutive patients undergoing all kind of lung resections for NSCLC. The first step aimed at auditing results of ERP on occurrence of postoperative complications and at assessing which ERP components were associated with improved short-term outcomes. We also audited late results by assessing long-term survival of patients in the first step of our study. The second step aimed at auditing on large-scale short-term results of the ERP in a real-life setting. In total, 166 patients were included in the first period. No postoperative death occurred. The overall adverse events rate was 30%. In multivariate analyzes, the only element associated with reduced adverse postoperative events was chest tube withdrawal within POD2. The 1-, 3- and 5-year survival rates were 97%, 86.1%, and 76.3%, respectively. In the second period, 1077 patients were included; 11 patients died during the postoperative period. The overall postoperative adverse event rate was 30.3%. Thoracoscore independently predicted postoperative death, the occurrence of complications (all-kind, minor, major, or respiratory ones). We conclude that compliance to ERP procedures and early chest tube removal are associated with reduced postoperative events in patients with lung resection surgery. Thoracoscore is a useful tool in predicting mortality and postoperative adverse events.Introduction: In spite of increasing diffusion, Enhanced Recovery Pathways (ERP) have been scarcely assessed in large scale programs of lung cancer surgery. The aim of this study was auditing our practice. Methods: A two-step audit program was established: the first dealing with our initial ERP experience in patients undergoing non-extended anatomical segmentectomies and lobectomies, the second including all consecutive patients undergoing all kind of lung resections for NSCLC. The first step aimed at auditing results of ERP on occurrence of postoperative complications and at assessing which ERP components are associated with improved short-term outcomes. We also audited late results by assessing long-term survival of patients in the first step of our study. The second step aimed at auditing on large-scale short-term results of the ERP in a real-life setting. Results: Over a one-year period, 166 patients were included. The median number of ERP procedures per patient was three (IQR 3–4). No postoperative death occurred. The overall adverse events rate was 30%. In multivariate analyzes, the only element associated with reduced adverse postoperative events was chest tube withdrawal within POD2 (OR = 0.21, 95% CI (0.10–0.46)). The 1-, 3-, and 5-year survival rates were 97%, 86.1%, and 76.3%, respectively. In the second period, 1077 patients were included in our ERP; 11 patients died during the postoperative period or within 30 days of operation (1.02%). The overall postoperative adverse event rate was 30.3%, major complication occurring in 134 (12.4%), and minor ones in 192 (17.8%). Respiratory complications occurred in 64 (5.9%). Thoracoscore independently predicted postoperative death, the occurrence of complications (all-kind, minor, major, or respiratory ones). Conclusions: Compliance to ERP procedures and early chest tube removal are associated with reduced postoperative events in patients with lung resection surgery. In a large setting scale, ERP can be applied with satisfactory results in terms of mortality and morbidity. Thoracoscore is a useful tool in predicting mortality and postoperative adverse events.

Comparison of perioperative outcomes of robotic-assisted versus video-assisted thoracoscopic right upper lobectomy in non-small cell lung cancer.

BackgroundRobotic-assisted thoracic surgery (RATS) has been widely used in the treatment of lung cancer. The perioperative outcomes of right upper lobectomy (RUL) using RATS and video-assisted thoracic surgery (VATS) were retrospectively investigated and compared. We aimed to summarize a single-center experience of RATS and 4-port unidirectional VATS in RUL, and to discuss the safety and the essentials of the surgery.MethodsWe retrospectively analyzed the 685 with non-small cell lung cancer (NSCLC) patients who underwent minimally invasive RUL in our center by the same surgical group from January 2015 to December 2019. Both RATS and VATS were performed with three ports with utility incision. The 685 participants were divided into RATS (335 cases) and VATS (350 cases) groups according to surgical method. Baseline characteristics and perioperative outcomes including dissected lymph nodes, postoperative duration of drainage, postoperative hospital stay, and incidence of postoperative complications were compared between the groups.ResultsIn the 685 patients enrolled, the baseline characteristics were comparable, and no postoperative 30-day mortality or intraoperative blood transfusion were observed. Compared with VATS, RATS had less surgical duration (90.22±12.16 vs. 92.68±12.26 min, P<0.001), less length of stay (4.71±1.37 vs. 5.26±1.56 days, P<0.001), and decreased postoperative duration of drainage (3.49±1.15 vs. 4.09±1.57 days, P<0.001). No significant difference was observed in the lymph nodes dissection, blood loss, conversion rate and morbidities. The cost of RATS was much higher than VATS (85,329.41±12,893.44 vs. 68,733.43±14,781.32 CNY, P<0.001).ConclusionsRobot assisted RUL had similar perioperative outcomes compared to VATS RUL lobectomy using similar three port with utility incision technique. The advantages of RATS included finer dissection of lymph node, relatively less operation time, earlier chest tube removal and discharge.

Advantages of a mini right axillary thoracotomy for congenital heart defect repair in children.

The mini right axillary thoracotomy is an alternative surgical approach to repair certain congenital heart defects. Quality-of-life metrics and clinical outcomes in children undergoing either the right axillary approach or median sternotomy were compared. Patients undergoing either approach for the same defects between 2018 and 2020 were included. Demographic details, operative data, and outcomes were compared between both groups. An abbreviated quality of life questionnaire based on the Infant/Toddler/Child Health Questionnaires focused on the patient's global health, physical activity, and pain/discomfort was administered to all parents/guardians within two post-operative years. Eighty-seven infants and children underwent surgical repair (right axillary thoracotomy, n = 54; sternotomy, n = 33) during the study period. There were no mortalities in either group. The right axillary thoracotomy group experienced significantly decreased red blood cell transfusion, intubation, intensive care, and hospital durations, and earlier chest tube removal. Up to 1 month, parents' perception of their child's degree and frequency of post-operative pain was significantly less after the right axillary thoracotomy approach. No difference was found in the patient's global health or physical activity limitations beyond a month between the two groups. With the mini right axillary approach, surrogates of faster clinical recovery and hospital discharge were noted, with a significantly less perceived degree and frequency of post-operative pain initially, but without the quality of life differences at last follow-up. While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of certain congenital heart lesions is a safe alternative to median sternotomy.

The Right Time for Chest Tube Removal in the Patient with Cardiac Surgery: A Systematic Review

Background: Chest tube insertion is recommended after cardiac surgery, and inserted annually for a large number of these patients. In addition to its benefits, the chest tube may have risks that are mismanaged. One of these risks is the possibility of pleural effusion, which can occur in high rates. Therefore, we conducted a systematic review to properly manage the chest tube and reduce its complications. Methods: This systematic review of cohort study asked the question: Is there enough evidence to determine the right time to remove the chest tube? We searched ISI Web of Science, PubMed, Scopus and Embase from 1 January 2015 to 30 September 2019 to identify retrospective or prospective cohort studies. Results: Three studies recommended early chest tube removal and two studies late removal. Of course, early and late removals in the studies had different meanings and time frames that were examined). Conclusion: More evidences and studies are needed to determine the right timing and management of the chest tube removal but our systematic review based on the available evidences revealed that if the chest tube removal occurs about 24 hours postoperatively, and with less than 100 ml drainage within the last 8 hours, it will reduce the risk of pleural effusion and improve many other outcomes.