Implications of modernized chest tube management after anatomic lung resection as an aspect of enhanced recovery after surgery (ERAS).

BACKGROUND

Following anatomic lung resection, chest tubes are required for fluid and air evacuation. Delayed removal can considerably prolong pain and immobilization during the postoperative course. We aimed to analyse the impact of an adaptation of the chest tube management on aspects regarding enhanced recovery after surgery (ERAS).

METHODS

Patients at our institution were treated according to two different protocols with the new protocol allowing chest tube removal up to a fluid output of 500 mL/24 h, and the standard protocol insisting on an output ≤200 mL/24 h. We retrospectively collected data in these two groups between January 2021 and December 2022 with a focus on aspects of ERAS.

RESULTS

A total of 150 patients were included in this retrospective observational study, of whom 62 (41.3%) were treated according to the new protocol and 88 (58.7%) with the standard protocol. There were no differences in the patient characteristics between the two groups. With the new protocol, chest tubes were removed at a mean output of 230±30.3 mL during the last 24 hours, whilst with the standard protocol mean output was 161±7.9 mL (P<0.001). If a higher fluid output was tolerated, chest tubes could be removed 1.5 days earlier {median 2 [interquartile range (IQR), 1-4] . 3.5 (IQR, 2-5) days, P=1.317e-05}. There was no difference in postoperative complications (Clavien-Dindo ≥3) between both cohorts [10 patients (16.1%) . 13 patients (14.8%), P=0.82] nor in the rate of re-interventions on the chest [8 patients (12.9%) . 15 patients (17%), P=0.65]. Furthermore, there was no difference in postoperative pain between both cohorts, with patients stating a mean pain score of 4.08±2.14 (4.18±2.21 . 4.01±2.09, P=0.56) on coughing on the first, 2.33±2.02 (2.16±1.96 . 2.44 ±2.07, P=0.46) on the third and 2.01±2.13 (1.88±2 . 2.11±2.21, P=0.58) on the fifth day after surgery on the visual analog scale (VAS). Opioid requirement for pain management were similar in both cohorts during the first 5 postoperative days (PODs). Patients from the new protocol cohort could be transferred from the intermediate-care unit one day sooner [median 1 (IQR, 1-3) . 2 (IQR, 1-3) days, P=0.89].

CONCLUSIONS

Chest tube removal up to a volume threshold of 500 mL/24 h after anatomic lung resection does not lead to increased complications, particularly thoracic interventions. All ERAS protocols should be designed accordingly.