Tunnel vision: seeking to reduce peritubular leakage after lung resection

Surgical resection continues to be the gold standard treatment for early-stage non-small cell lung cancer (NSCLC). Routine placement of a thoracostomy tube is performed in the majority of centers to facilitate evacuation of postoperative air and fluid from the pleural space (1,2). At time of insertion in the operating room, it is important to achieve adequate tissue approximation around the tube to prevent either leakage of intrapleural material or entrainment of extrathoracic air, especially in thin or cachectic patients who have minimal chest wall soft tissue. As the patients recover from their operation, chest tube removal is determined by resolution of any air leak and when pleural fluid output decreases to a level deemed permissible by the surgical team (3). Of note, the degree of permissible daily pleural fluid output remains controversial, with most surgeons designating a value between 100 to 250 mL/24 h as the upper limit for chest tube removal (4). While the chest tube is in place, fluid leakage can occur from the site of insertion if the tube was not secured at time of surgery and if dressings are not occlusive (5). Failure to control peritubular leakage can be a frequent problem with vexing consequences such as skin irritation, wound breakdown, and infection, which can become a major source of patient discomfort (6).

In the May 2023 issue of Annals of Thoracic Surgery, Yun and colleagues from the Affiliated Hospital of Qingdao China reported a single center randomized controlled trial assessing a novel strategy for chest tube placement meant to mitigate peritubular leakage after lung resection (7). A group of 199 patients undergoing lung resection (lobectomy, segmentectomy, or wedge resection) for NSCLC via video-assisted thoracic surgery (VATS) or robotic-assisted thoracic surgery (RATS) between February 2021 to August 2021 were enrolled. Participants were randomly assigned in a 1:1 fashion to either the control/regular (RCP, n=101) or experimental/modified (MCP, n=98) chest tube placement groups. In the RCP group, the chest tube was inserted directly into the thoracic cavity through the 1–1.2 cm camera port incision located in the seventh intercostal space in the mid-axillary line. By contrast, the chest tube of the MCP group was subcutaneously tunneled through the camera port skin incision and then inserted into the next cephalad intercostal space. The primary outcomes measured included the incidence of peritubular leakage of fluid and air. An instance of fluid leakage was determined as the complete infiltration of the peritubular portion of dressing, and air leakage was determined by the sound of airflow or the presence of bubbles when wiping with iodophor.

For the entire study population, the total chest tube duration was approximately three days and overall hospital length of stay was six days. The authors observed that when compared to the control group, the MCP group showed a statistically significant decrease in the incidence of peritubular fluid leakage after surgery (39.6% vs. 18.4%, P=0.007) and after chest tube removal (26.7% vs. 11.2%, P=0.005). This improvement was also confirmed for the rate of air leakage (14.9% vs. 5.1%, P=0.022). As a secondary outcome, the volume of peritubular fluid leakage, as expressed by the total number of thoracostomy site dressing changes during admission, was quantified and findings mirrored the primary outcomes with MCP group requiring fewer total dressing changes (5.02±2.30 vs. 3.48±0.94, P<0.001). Multivariate logistic regression analysis identified the RCP method [odds ratio (OR): 6.385, 95% confidence interval (CI): 2.911–14.003, P<0.001], age >60 years (OR: 2.587, 95% CI: 1.230–5.437, P=0.012), and segmentectomy (OR: 4.729, 95% CI: 1.293–17.295, P=0.019) as being associated with increased severity of peritubular fluid leakage.

Noteworthy limitations that were outlined by Yun et al. included the study’s single center nature and the relatively small cohort of demographically homogenous patients. The authors also highlighted the difficulty they experienced in measuring peritubular fluid volume. The amount of leakage was characterized by the number of dressing changes as opposed to a granular volume. A more precise method for quantifying the results would be ideal but elusive given the inherent nature of peritubular leakage. Additionally, there was no mention of routine chest X-ray utilization during the post-operative period. The practice of daily chest X-rays to monitor both effusion and pneumothorax is common at many centers. While it is conceivable that a hospital with limited resources may not have routine access to chest X-ray, the lack of post-operative imaging represents a limitation to this study given the inability to report on associated chest tube complications such as pneumothorax. From a methodological standpoint, there is no mention of blinding experimental groups from study or hospital personnel. However, from a practical perspective, there would have been no visible difference at chest tube or incision sites between the two groups. Therefore, blinding of the hospital staff may not have been required. Theoretically, one method of blinding from hospital staff would be withholding the operative note from the chart, but this would not be expected to change the conduct of routine postoperative care. Furthermore, Yun et al. concluded that the MCP method was “not inferior”, however this is not supported by the trial design as the standard non-inferiority methods were not employed.

The drainage system utilized for this trial is worthy of mention. The authors of this study denote the usage of “a closed drainage bottle” for the collection of thoracostomy tube contents. The use of this language infers the utilization a single-unit collection system. Single-unit collection systems are effective, safe, and affordable options for thoracostomy tube drainage, but have inherent disadvantages (8). As pleural fluid accumulates into the collection chamber, the chamber’s overall fluid level will rise, meaning a greater pressure is needed for effective air drainage (9). Three-unit collection systems address the issues of single-unit collection systems by introducing separate compartments for drainage, air sealing, and suction control. The Atrium Oasis^© (Getinge, Gothenburg, Sweden) and Pleur-Evac^© (Teflex Medical, Wayne, PA, USA) are examples of commonly used three-unit collection systems that allow for efficient measurement of fluid output (10). The utilization of a single unit collection system is fairly uncommon when compared to three chamber systems, which therefore limits the generalizability of the study by Yun et al.

Readers should also be aware that the chest tube placement method utilized for the RCP group was previously scrutinized by Palleschi et al. for what was considered “suboptimal angulation” between the chest wall/pleural cavity with potential (but not proven) untoward outcomes including development of air or fluid collections and infection (11). Given how common peritubular leakage or other complications associated with chest tube management, undoubtedly many surgeons have devised their own preventative methods to preemptively avoid these pitfalls. For example, “tunneling”, wherein a subcutaneous tract is created one interspace caudad to the pleural entry level to assist with optimal positioning (5). Tunneling is a longstanding practice performed during chest tube insertion in certain situations such as in trauma and urgent bedside procedures during which it is necessary to make the entry through the intercostal space larger than the chest tube to ensure safe placement into the pleural cavity. Our center has adopted a different approach to tunneling the chest tube. In our technique, a separate skin incision is made 1 to 1.5 cm inferior and anterior to the camera port. Next, a clamp is used to subcutaneously tunnel the distal end of the chest tube from the camera port into new incision. Finally, the end of the chest tube is inserted into the pleural cavity through the camera port intercostal entry site. This allows for the camera port skin incision to be tightly closed while ensuring a suitable angle for chest tube entry into the chest but comes at the expense of an additional skin incision. The subcutaneous tunnel also theoretically helps to decrease the rate pneumothorax after chest tube removal.

Modification of standard protocol for chest tube placement may also serve to reduce associated symptomology. There have been a multitude of studies have explored methods to reduce the pain associated with thoracostomy tube placement. A trial comparing the insertion of a conventional 20-Fr chest tube with a 7-Fr central venous catheter for thoracic drainage following lung-wedge resection showed that 7-Fr central venous catheter placement was associated with a statistically significant reduction in patient-reported pain scores, although the reduced diameter limited drainage capacity (12). Another study comparing 19-Fr Blake drains to 28-Fr conventional drains in patients receiving lobectomy for lung cancer showed no significant difference in the amount of drainage between groups (13). The use of a 19-Fr Blake drain was also shown to be associated with improved wound healing (13). In some instances, the complications associated with chest tubes can be avoided entirely by not placing a tube at all. A 2017 meta-analysis synthesized data from randomized controlled trials focused on chest-tube management and provided evidence that omitting chest tube placement in select instances does not increase the incidence of postoperative morbidity in carefully selected patient populations receiving VATS lobectomy or wedge resection (14). The four criteria proposed when considering deferral of chest tube after lung resection included: (I) absence of intraoperative air leak; (II) no severe emphysematous or bullous disease; (III) no significant pleural adhesions; and (IV) no preoperative chronic pleural effusion requiring intervention prior to lung surgery. These intriguing and provocative studies serve to move surgeons out of their dogmatic comfort zones with the worthy goal of safe, incremental improvements to patient care which is necessary for the continued evolution of the field of surgery.

Yun and his colleagues should be commended for accepting the daunting challenge of constructing and completing a prospective, randomized controlled trial focused on a surgical technique. To our knowledge, the topic of chest tube peritubular leakage has not been thoroughly explored in the literature and Yun et al. should be applauded for their contribution. The healthcare team at the Affiliated Hospital of Qingdao China deserves special mention for impressively executing the rigorous study methods (including obtaining data at two-hour intervals around the clock until discharge) in an inspired effort to quantify the “unquantifiable”. Their laudable efforts towards this study’s completion are certainly worthy of praise and serve as a strong example for other groups to emulate.

Going forward, future studies on optimizing chest tube insertion after lung resection could focus on optimizing comfort without impacting effectiveness. For example, smaller tubes with more drainage holes and increased flexibility could achieve this delicate balance. As centers are considering same day discharge with chest tubes, insertion techniques and methods of how securing to the patient could be improved to increase safety for chest tube management at home with specific attention to prevention of infection. Longer subcutaneous tunnels would be one method of decreasing infection risk, similar to the concept of Pleurx^© catheters (BD, Franklin Lakes, NJ, USA). Finally, building upon studies such as those noted above, a move towards the omission of the chest tube altogether after elective thoracic surgery would be an optimistic goal (15).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Clinical Trials Review. The article has undergone external peer review.

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