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.

Early chest tube removal following single-direction versus conventional uniportal video-assisted thoracoscopic lobectomy: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective    To explore the feasibility of early chest tube removal following single-direction uniportal video-assisted thoracoscopic surgery (S-UVATS) anatomical lobectomy. Methods    The clinical data of consecutive VATS lobectomy by different surgeons in Xuzhou Central Hospital between May 2019 and February 2022 were retrospectively reviewed. Finally, the data of 1 084 patients were selected for analysis, including 538 males and 546 females, with a mean age of 61.0±10.1 years. These patients were divided into a S-UVATS group with 558 patients and a conventional group (C-UVATS) with 526 patients according to the surgical procedures. The perioperative parameters such as operation time, blood loss were recorded. In addition, we assessed the amount of residual pleural effusion and the probability of secondary thoracentesis when taking 300 mL/d and 450 mL/d as the threshold of chest tube removal. Results    Tumor-negative   surgical margin was achieved without mortality in this cohort. As compared with the C-UVATS group, patients in the S-UVATS group demonstrated significantly shorter operation time (P<0.001), less blood loss (P=0.002), lower rate of conversion to multiple-port VATS or thoracotomy (P=0.003), but more stations and numbers of dissected lymph nodes as well as less suture staplers (P<0.001). Moreover, patients in the S-UVATS demonstrated shorter chest tube duration, less total volume of thoracic drainage and shorter postoperative hospital stay, with statistical differences (P<0.001). After excluding patients of chylothorax and prolonged air leaks>7 d, subgroup analysis was performed. First, assuming that 300 mL/d was the threshold for chest tube removal, as compared with the C-UVATS group, patients in the S-UVATS group would report less residual pleural effusion and less necessitating second thoracentesis with residual pleural effusion>500 mL (P<0.05). Second, assuming that 450 mL/d was the threshold for chest tube removal, as compared with the C-UVATS group, the S-UVATS group would also report less residual pleural effusion and less necessitating second thoracentesis with residual pleural effusion>500 mL (P<0.05). Further multivariable logistic regression analysis indicated that S-UVATS was significantly negatively related to drainage volume>1 000 mL (P<0.05); whereas combined lobectomy, longer operation time, more blood loss and air leakage were independent risk factors correlated with drainage volume>1 000 mL following UVATS lobectomy (P<0.05). Conclusion    The short-term efficacy of S-UVATS lobectomy is significantly better than that of the conventional group, indicating shorter operation time and less chest drainage. However, early chest tube removal with a high threshold of thoracic drainage volume probably increases the risk of secondary thoracentesis due to residual pleural effusion.