What is the most optimal postoperative chest tube placement method after lung resection?

Introduction

Placement of a chest tube after lobectomy and segmentectomy is considered as an essential procedure, but it causes patient pain and hinders postoperative mobilization. So, we must manage it appropriately. The position of the chest tube tip and fixation of the chest tube are quite important, and sealing the drain insertion site is also important for drain management for accurate information and wound healing at the insertion site.

Chest tube management

There are some reports that there is no need to place the chest tube after video-assisted thoracoscopic wedge resection of the lung (1,2), and there is also report that the chest tube is removed in the operating room after thoracoscopic major resection for cancer for selected patients (3). However, considering the fundamental purpose of placing a chest tube for information to avoid serious postoperative complications, postoperative chest tube placement is essential for major resection for cancer (4). Although there is no confirmed guideline for chest tube management, it needs to manage the chest tube based on the experience and the results of small-scale studies. Several answers to clinical questions in actual clinical practice have been clarified, leading to the establishment of standard drain management methods. For example, regarding the number of chest tube placement, basically single chest tube is sufficient (5). Regarding suction after chest tube placement, water seal is desirable not to use intrapleural suction (6,7). There is no need to stick to 200 mL/day as a criterion for chest tube removal (8,9). There is no difference in incidence rate of pneumothorax after removal of chest drainage tubes whether to remove chest tube with inhalation or exhalation timing (10). Management with digital chest tubes can be an effective chest tube management method because it can be objectively evaluated (11).

Additionally, a nurse or nurse practitioner should be able to visibly monitor the postoperative status of the patient even when the general thoracic surgeon is not available, such as during the night after surgery. We believe that the placement of a drain as information is necessary after a lobectomy or segmentectomy, and that the chest drain should not be removed immediately after the operation even if there is no leakage or active bleeding immediately after the operation.

Chest tube placement

Evidenced-based management methods are being established based on the experiences of our predecessors. The purpose of chest tube placement is strongly implicated as information for obtaining adequate postoperative intrathoracic information. Although there was no problem when the chest was closed, it is to be able to deal with it immediately if postoperative bleeding or severe pneumothorax occurs. Video-assisted thoracic and robot-assisted thoracic surgery have become mainstream for lung cancer resection, and chest drain management methods have changed. It was reported the removal at the operation room after surgery (3), or there is no problem in removing the chest drain if the pleural effusion decreased over time, instead of the standard for drainage of 200 mL or less in 24 hours (12). The criteria for chest tube removal are changing.

Regarding the chest tube placement, the lower intercostal port insertion site is often used and left as it is. Especially in the cases of the da Vinci port which material of the port is hard and the muscle and subcutaneous tissue are crushed, and the shape of the port remains. Unless some measures are taken, pleural effusion and air from inside-out drain after operation will occur and it may increase the risk of postoperative empyema and wound infection caused by retrograde infection. A simple technique is to tightly close the intercostal muscles and subcutaneous tissues of the insertion site with sutures, but it is often difficult to completely block the leakage of pleural effusion and air. As a method to separate the intrathoracic and extrathoracic cavities, it seems that some thoracic surgeons are performing the indwelling method by passing a chest tube through the one intercostal space above the skin (13,14). With this method, the insertion part of the drain can be more tightly closed, and the insertion direction of the chest tube into the thoracic cavity can be fixed, so that the tip of the chest tube can be left in an ideal position. Regarding this modified chest tube placement method, Yun et al. published a small-scale randomized study and proved its usefulness (14).

Using this method, it should be taken care not to damage the intercostal arteriovenous nerves between the upper ribs, as the intercostal space is additionally damaged. It must be taken care to avoid unnecessary bleeding.

With the above method, it may be possible to easily treat the wound after extubation. Since the skin incision and the intercostal space connection to the thoracic cavity are misaligned, no suture is performed after the chest tube is removed, and the wound heals cleanly by applying tape to the wound and applying pressure by gaze and skin tape (15).

It is useful because there is no need to remove sutures and there is no problem with wound adaptation.

To prevent postoperative pain and pleural fluid leakage from the drain insertion site, there is an option to place a coaxial tube. In addition, it is necessary to consider the thickness and shape of the drain tube (flat type, round type, etc.) to reduce the pain caused by drain placement and to prevent the drain from becoming boring. However, as there is no clear best drain in terms of thickness and shape, the current situation seems to be that the choice is based on the experience and preferences of individual doctors.

Conclusions

Toward fast-track surgery, it is extremely important to establish an evidence-based chest tube management method. Crawling an intercostal drain and placing it in the thoracic cavity means damaging one more intercostal tissue. Personally, I try to choose intercostal drain placement when the patient is thin and postoperative pleural effusion leakage from the drain insertion site is anticipated, or when the patient is on steroids and drain infection is feared. In using this method, care must be taken to avoid unnecessary bleeding. Establishment of a chest tube management method which can reduce the burden not only on the patient but also on the medical staff is desired.

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.

Peer Review File: Available at https://actr.amegroups.com/article/view/10.21037/actr-23-25/prf

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