Safety of early discharge with a chest tube after pulmonary segmentectomy

Safety of one 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage after uniportal video-assisted thoracoscopic surgery pneumonectomy

OBJECTIVES

Uniportal video-assisted thoracoscopic surgery pneumonectomy (U-VATS-P) is feasible and safe from a perioperative standpoint. How to choose the proper chest tube and drainage method is important in enhanced recovery after surgery (ERAS) protocols. In this study, we aimed to assess the safety of one 8.5-Fr (1Fr = 0.333 mm) pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P.

METHODS

We retrospectively reviewed a single surgeon's experience with U-VATS-P for lung cancer from May 2016 to September 2022. Patients were managed with one 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P. The clinical characteristics and perioperative outcomes of the patients were retrospectively analyzed.

RESULTS

In total, 77 patients had one 8.5-Fr pigtail catheter placed for postoperative continuous open gravity drainage after U-VATS-P for lung cancer. The mean age was 60.9±7.39 (40-76) years; The mean FEV1 was 2.1±0.6 (l/s), and the mean FEV1% was 71.2±22.7. The median operative time was 191.38±59.32 min; the mean operative hemorrhage was 109.46±96.56 ml; the mean duration of postoperative chest tube drainage was 6.80±2.33 days; the mean drainage volumes in the first three days after operation were 186.31±50.97, 321.97±52.03, and 216.44±35.67 ml, respectively; and the mean postoperative hospital stay was 7.90±2.58 days. No patient experienced complications resulting from chest tube malfunction. Ten patients experienced minor complications. One patient with nonlife-threatening empyema and bronchopleural fistula required short rehospitalization for anti-inflammatory therapy and reintubation. Three patients with chylothorax were treated with intravenous nutrition. Four patients had atrial fibrillation that was controlled by antiarrhythmic therapy. Two patients had more thoracic hemorrhagic exudation after the operation, which was found in time and was cured effectively, so they were discharged from the hospital uneventfully after early hemostatic therapy and nutritional support.

CONCLUSIONS

All patients in this study received early postoperative rehabilitation, and the rate of relevant complications was low. We therefore recommend a single 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage as an effective, safe and reliable drainage method for the management of U-VATS-P.

Undergoing Lung Surgery (PSA-Lung) was appropriate for symptom assessment after discharge

PURPOSE

To examine whether a 7-day or 24-h recall period of Perioperative Symptom Assessment for Patients Undergoing Lung Surgery (PSA-Lung) was appropriate for symptom assessment after discharge.

METHODS

A total of 377 patients were recruited in a cohort study of patients who underwent lung surgery. We measured patient symptoms daily and weekly using the two recall period versions of the PSA-Lung scale, respectively. The psychometric properties of both versions were calculated. Spearman rank correlation coefficients and kappa (k) coefficients were used to measure the association between items score measured by the two version scales each week. Cohen's d effect size and mixed linear model were used to measure responsiveness to change over time.

RESULTS

Spearman rank correlation coefficients between the symptom scores generated by the 7-day and 24-h versions (range 0.48-0.77; all P < 0.05). The correlations increased in patients in stable condition (weekly symptom change < 2). Cronbach's α coefficients for both ratings were > 0.87 and both had good test-retest reliability. The longitudinal analysis and Cohen's d effect sizes showed that both ratings had good ability to detect changes in all items.

CONCLUSION

The 7-day retrospective scale was as effective as the 24-h retrospective scale in terms of psychometric performance. In the stage where the patient's symptoms change rapidly, it is recommended to use the 24-h retrospective scale for symptom monitoring. On the contrary, in a stable state, it can be considered to use the 7-day retrospective scale for monitoring to reduce the patient's burden.

Complications of Outpatient Chest Tube Management for Prolonged Air Leaks After Pulmonary Surgery

PURPOSE

Air leaks are common after pulmonary surgery. Prolonged air leaks (PALs) may persist through discharge and often are managed with one-way valve devices (OWD). We sought to determine the course and complications of patients discharged with OWDs, risk factors for complications, and to evaluate the utility of clamp trials before chest tube (CT) removal.

METHODS

Single-institution, retrospective review of patients discharged with a OWD after pulmonary surgery between 2008 and 2022. Charts were examined for the presence of complications and CT duration. Differences in CT duration were compared by using the Wilcoxon rank-sum test.

RESULT

Sixty-four of 1917 (3.3%) pulmonary surgeries resulted in OWD use. Twelve of 64 (19%) patients discharged with a OWD suffered a complication. Nine of 64 (14%) had a CT-related readmission, and seven of 64 (11%) required PAL intervention. Patients sustaining a complication demonstrated longer CT durations before complication compared with duration in patients without complications, with median days of 13 [IQR 6-21] vs. 7 [IQR 6-12], p = 0.04). Five (7.8%) OWD patients developed an empyema; only one (20%) occurred before a CT duration of 14 days. Sixteen of 64 (25%) patients underwent a clamp trial before CT removal. One of ten (10%) failed even with no air leak present, whereas one of six (17%) failed with a present/questionable air leak.

CONCLUSIONS

One-way valve device use has a substantial complication rate, and chest tube duration is a risk factor. In-hospital interventions might benefit patients with larger leaks that likely require prolonged OWD use. Because clamp trials occasionally fail, we contend that a clamp trial is the safest course before CT removal.

Discharging Patients Home With a Chest Tube and Digital System After Robotic Lung Resection

BACKGROUND

Our objective is to assess the feasibility, safety, and outcomes for patients discharged home with a chest tube connected to a digital drainage system after robotic pulmonary resection.

METHODS

This was a retrospective analysis of a prospectively collected database as a quality improvement initiative. All patients had planned discharge on postoperative day one (POD1) after robotic pulmonary resection. Those with an air leak were discharge home with a chest tube connected to a digital drainage system with daily communication with the surgeon.

RESULTS

From January 2019 to February 2023 there were 580 consecutive robotic resections, of which 69 (12%) patients had an air leak on POD1; 38 of 276 (14%) after lobectomy, 24 of 226 (11%) after segmentectomy, and 7 of 78 (9%) after wedge resection. Of these 69 patients, 52 patients (75%) were discharged on POD1, 15 patients (22%) on POD2, and 2 patients (3%) on POD3. Chest tubes were removed a median outpatient chest tube duration was 4 days (interquartile range, 3-5 days). Of the 69 patients sent home with a digital drainage system, there was 1 complication requiring readmission for increasing subcutaneous emphysema. Five patients (7%) had system malfunctions that required return to our clinic for problem-solving. There were no 30- or 90-day mortalities.

CONCLUSIONS

Patients who undergo robotic pulmonary resection and have an air leak can be safely and effectively discharged on the first postoperative day and managed as an outpatient by using daily texts and or videos with pulse oximetry data on a digital drainage system with limited morbidity.

Factors associated with safe and successful postoperative day 1 discharge after lung operations: a systematic review and meta-analysis

BACKGROUND

A shorter length of stay (LOS) is associated with fewer hospital-acquired adverse conditions and decreased utilization of hospital resources. While modern perioperative care protocols have enabled some ambitious surgical teams to achieve discharge as early as within postoperative day 1 (POD1), most other teams remain cautious about such an approach due to the perceived risk of missing postoperative complications and increased readmission rates. We aimed to identify factors that would help guide surgical teams aiming for safe and successful POD1 discharge after lung resection.

METHODS

We searched the PubMed, Embase, Scopus, Web of Science and CENTRAL databases for articles comparing perioperative characteristics in patients discharged within POD1 (DWPOD1) and after POD1 (DAPOD1) following lung resection. Meta-analysis was performed using a random-effects model.

RESULTS

We included eight retrospective cohort studies with a total of 216,887 patients, of which 22,250 (10.3%) patients were DWPOD1. Our meta-analysis showed that younger patients, those without cardiovascular and respiratory comorbidities, and those with better preoperative pulmonary function are more likely to qualify for DWPOD1. Certain operative factors, such as a minimally invasive approach, shorter operations, and sublobar resections, also favor DWPOD1. DWPOD1 appears to be safe, with comparable 30-day mortality and readmission rates, and significantly less postoperative morbidity than DAPOD1.

CONCLUSIONS

In select patients with a favorable preoperative profile, DWPOD1 after lung resection can be achieved successfully and without increased risk of adverse outcomes such as postoperative morbidity, mortality, or readmissions.

Feasibility and applicability of pulmonary nodule day surgery in thoracic surgery

Background

More patients with lung diseases were identified with low-dose computed tomography (CT) popularization and increasing physical examination awareness. Day surgery was routinely conducted in many departments as a relatively mature diagnosis and treatment mode. Thus, this study aimed to assess the feasibility of day surgery in thoracic surgery for pulmonary surgery and provide guidance for selecting suitable patients.

Methods

This study retrospectively analyzed the clinical data of patients with pulmonary nodule surgeries. Patients were divided into the day and routine surgery groups following chest tube removal within 48 h postoperatively and the discharge criteria. Each group was further divided into the wedge and anatomic lung resection groups. The feasibility and applicability of day surgery in thoracic surgery was evaluated by calculating the percentage of the day surgery group and comparing the clinical data of the two groups, and corresponding guidance was given for selecting suitable patients for day surgery.

Results

The day surgery group accounted for 53.4% of the total number of patients in both groups. Data comparison revealed differences in age, hypertension, coronary heart disease, pulmonary function index, nodule localization, pleural adhesion, total postoperative drainage, and complications in the wedge resection and age, gender, smoking history, pulmonary function indexes, intraoperative adhesions, operative duration, total postoperative drainage volume, and complications in the anatomic lung resection (P < 0.05). There were no significant differences in the rates of re-hospitalization (1/172 ratio 1/150) and re-drainage (0/172 ratio 1/150) (P > 0.05).

Conclusion

This study concluded that more than half of the pulmonary surgery can be applied to the treatment mode of day surgery, and day surgery can be applied to the screened patients. It conforms to the concept of accelerated rehabilitation and can speed up bed turnover so that more patients can receive high-level medical treatment promptly.

Safety and Feasibility of Video-Assisted Thoracoscopic Day Surgery and Inpatient Surgery in Patients With Non-small Cell Lung Cancer: A Single-Center Retrospective Cohort Study

Background and Objective: This study was undertaken to evaluate how safe and viable the use of video-assisted thoracoscopic day surgery (VATDS) is for individuals diagnosed with early-stage non-small cell lung cancer (NSCLC).

Methods: Data obtained from the selected patients with NSCLC who underwent video-assisted thoracoscopic surgery (VATS) in the same medical group were analyzed and a single-center, propensity-matched cohort study was performed. In total, 353 individuals were included after propensity score matching (PSM) with 136 individuals in the day surgery group (DSG) and 217 individuals in the inpatient surgery group (ISG).

Results: The 24-h discharge rate in the DSG was 93.38% (127/136). With respect to the postoperative complications (PPCs), no difference between the two groups was found (DSG vs. ISG: 11.76 vs. 11.52%, p = 0.933). In the DSG, a shorter length of stay (LOS) after surgery (1.47 ± 1.09 vs. 2.72 ± 1.28 days, p < 0.001) and reduced drainage time (8.45 ± 3.35 vs. 24.11 ± 5.23 h, p < 0.001) were found, while the drainage volume per hour (mL/h) was not notably divergent between the relevant groups (p = 0.312). No difference was observed in the cost of equipment and materials between the two groups (p = 0.333). However, the average hospital cost and drug cost of the DSG were significantly lower than those of the ISG (p < 0.001).

Conclusion: The study indicated that the implementation of VATDS showed no difference in PPCs, but resulted in shorter in-hospital stays, shorter drainage times, and lower hospital costs than inpatient surgery. These results indicate the safety and feasibility of VATDS for a group of highly selected patients with early-stage NSCLC.

Suction Versus Nonsuction Drainage After Uniportal Video-Assisted Thoracoscopic Surgery: A Propensity Score-Matched Study

Background

Uniportal video-assisted thoracoscopic surgery (UniVATS) was utilized with a rapid growth. The evidence is sparse, however, on whether to add external suction to water-seal drainage for chest drainage after UniVATS. This retrospective propensity score-matched study aimed to identify the necessity of adding external suction to chest drainage after UniVATS.

Methods

Patients with lung cancer who underwent UniVATS were included from our prospectively maintained database. Patients were divided into two cohorts based on the addition of external suction to postoperative water-seal drainage or not. Propensity score-matched analysis was performed to identify the impact of suction on chest tube duration, incidence of persistent air leak, hospital stay, and hospitalization cost. Multivariable model with interaction terms was constructed to identify impact of covariables on effect of suction.

Results

The two cohorts matched well on baseline characteristics (nonsuction: 173; suction: 96). Compared with nonsuction group, suction group showed longer median chest tube duration (3 vs. 2 days, p = 0.003), higher incidences of persistent air leak (9.4% vs. 1.2%, p = 0.003), persistent drainage (16.8% vs. 5.8%, p = 0.007), and reduced drainage volume within first 3 postoperative days (386.90 vs. 504.78 ml, p = 0.011). Resection extent was identified to mediate the relationship between suction and chest tube drainage.

Conclusions

These findings discouraged adding external suction to water-seal drainage after UniVATS regarding longer chest tube duration and more persistent air leak. Patients undergoing lobectomy would benefit more from water-seal drainage without external suction compared with those doing sublobectomy.

Video-Assisted Thoracoscopic Day Surgery for Patients with Pulmonary Nodules: A Single-Center Clinical Experience of 200 Cases

Background

We reviewed our experience with 200 patients who underwent video-assisted thoracoscopic day surgery (VATDS) at the Day Surgery Center at West China Hospital to identify the safety and feasibility of VATDS and assess the value of novel management in patients with pulmonary nodules.

Methods

Between June 2019 and December 2020, 200 patients with pulmonary nodules underwent VATDS at the Day Surgery Center at West China Hospital. The medical records of these 200 patients were reviewed for age, sex, preoperative history, operative and pathological findings, amount of daily chest tube drainage, procedure method and duration, length of stay (LOS), visual analog scale (VAS), and postoperative pulmonary complications (PPCs).

Results

There were 45 male and 155 female patients with a median age of 43 years (range 18 to 58 years). A total of 158 (79.00%) patients were diagnosed with lung adenocarcinoma, 35 (17.50%) were diagnosed with chronic inflammation with fibrous hyperplasia, and seven (3.50%) were diagnosed with granulomatous inflammation with necrosis. The mean LOS of the 200 patients was 1.25±0.95 days, and 187 (93.50%) patients were discharged within 24 hours as planned. Thirteen patients were transferred to the thoracic surgery ward for further treatment because of PPCs. The median VAS was 3 points (range 1 to 7 points), and the rate of PPCs was 11.50%.

Conclusion

Two hundred patients underwent VATDS with an acceptable 24-hour discharge rate. However, selection of patients for VATDS is required, and the implementation of VATDS on a larger scale requires further discussion.

Feasibility, safety and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery

AIMS

The aims of this study were to evaluate the safety, feasibility and outcomes of ambulation within 2 h after thoracoscopic surgery in patients with lung cancer.

BACKGROUND

There are no consensus guidelines on the ideal time for early ambulation following thoracic surgery, although enhanced recovery programmes have been proposed since years.

METHODS

This non-randomized, concurrent-control study was conducted on patients who underwent thoracoscopic surgery between October 2020 and February 2021. Participants were assigned to either the observation group (ambulation within 2 h of extubation) or the control group (ambulation on the first postoperative day).

RESULTS

Of the 325 patients who were eligible, 227 were included in the study. Eighty-three per cent of patients were able to walk any distance within 2 h of extubation, and no adverse events occurred in patients. The length of hospital stay and time to first postoperative flatus were significantly shorter in the observation group than in the control group. There were no differences in the occurrence of postoperative complications and orthostatic hypotension, readmission rate and 6-min walk distance at discharge.

CONCLUSION

Ambulation within 2 h of extubation was safe and feasible and could lead to better recovery in patients with lung cancer undergoing thoracoscopic surgery.