The evolution of chest tube management following lung cancer surgery: many options, scarce evidence.

After lung cancer surgery, a chest tube is routinely placed to prevent complications such as a pneumothorax or pleural effusion. However, chest tube placement often comes with patient discomfort, impaired mobilization, and prolonged hospitalization, necessitating improved chest drain policies to reduce drainage time or even omit chest drains. In recent years, extensive research has been conducted on chest tube removal criteria and the optimization of thoracic drainage strategies, particularly on the use of suction versus water seal and digital drainage systems versus analogue drainage systems. To date, no clear consensus has been reached on either removal criteria or optimal drainage technique, mostly due to conflicting study outcomes and a lack of high-quality evidence. This review aims to provide a comprehensive overview of the current understanding of thoracic drainage in the context of lung cancer surgery and to identify potential gaps in current knowledge. It outlines the historical development of thoracic drainage and describes key aspects of current drainage strategies, incorporating both evidence-based and expert-opinion-based findings. Furthermore, we propose several strategies how chest drainage techniques can continue to evolve and become less invasive with the introduction of the enhanced recovery after surgery (ERAS) protocol, and thereby explore the possibilities of omitting chest tubes after anatomical resection, as well as patient-specific drainage strategies. In conclusion, standardized definitions and removal criteria for chest drainage are crucial to unify and optimize postoperative care in thoracic surgery. Developing personalized, evidence-based strategies will improve patient outcomes and advance minimally invasive approaches within the ERAS pathways.