Management of chest tube after thoracoscopic lung resection in children with congenital lung malformation: a multicenter retrospective study

Abstract

This study aimed to investigate the safety and effect of omitting chest tubes after thoracoscopic lobectomy in children with congenital lung malformation. A multicenter retrospective study was performed with 632 thoracoscopic lobectomy CLM patients in four hospitals between 2014.1 and 2023.1, which were divided into non-chest tube (NCT)group and chest tube (CT)group. Baseline data, operation and follow-up outcomes were compared. In total, 312 patients were included in the NCT group, and 320 in the CT group. There were no statistically significant differences in baseline data between the two groups. The FLACC scale score in the NCT group was less than the CT group (2.7 ± 0.43 vs. 5.8 ± 0.26 p = 0.027). The median length of postoperative hospital stay in the CT group was significantly longer than the NCT group (5 d vs.3 d, p = 0.045). Eight (2.5%) patients developed chest tube related infections in the CT group(p = 0.004). Six patients developed atelectasis in the NCT group, which was significantly less than the 18 patients in the CT group(p = 0.014). No chest tube placement in selected CLM pediatric patients may be safe and avoid chest tube-related complications, which may also contribute to a rapid recovery.

Introduction

Placing a chest tube is currently a routine procedure after thoracic surgery, with the aim of draining the gas and liquid from the thoracic cavity during and after surgery, and the aim of monitoring for persistent air leakage, bleeding, and other life-threatening situations in the thoracic cavity^1,2. However, a chest tube also brings a series of impacts and complications. For example, infections, pain, and atelectasis are caused by drainage tubes³; Moreover, placing a chest tube can prolong hospitalization and affect enhanced recovery after surgery process⁴. A tubeless strategy is an important part of enhanced recovery after surgery^5,6. Currently, many scholars have proposed reducing the number of postoperative drainage tubes, reducing the time for postoperative drainage tube placement and not installing thoracic drainage tubes in some cases^7–11.

In the field of pediatric thoracic surgery, CLM is currently one of the most common thoracic diseases in children and requires complete resection of the diseased lung tissue to achieve cure¹². Currently, lobectomy is widely accepted as the standard surgical method for this disease^13,14. With the development of minimally invasive technology, to reduce the occurrence of complications of thoracotomy, an increasing surgeons tend to use thoracoscopy minimal invasive procedures to treat these patients¹⁵. A previous study found that when some CLM cases without severe infection received thoracoscopic lobectomy, meanwhile, ensured the accurate treatment of lung hilum during operation, there are no obvious complications such as pleural effusion or fluid accumulation, and postoperative air leakage is rare after surgery¹⁶. Therefore, for such patients, we tried not to place a chest tube, which had high safety and effectiveness in the early follow-up and could achieve rapid recovery.

However, previous studies lacked a reasonable control group to verify the safety and efficacy of this protocol. Therefore, we conducted a multicenter case-control study in conjunction with three other hospitals to demonstrate the safety and efficacy of omission of chest tubes after thoracoscopic lobectomy in children with CLM and to explore the indications for chest tube placement after thoracoscopic lung resection in children.

Methods

A multicenter retrospective study was performed with CLM pediatric patients who underwent thoracoscopic lobectomy in four hospitals between January 2014 and January 2023.This study was approved by the Institutional Review Board of West China Hospital of Sichuan University (No. 1284), including any relevant details. All methods were performed in accordance with relevant guidelines and regulations. This retrospective study used a database from which the patients’ identification information had been removed.

In this study, CLM patients who received thoracoscopic lobectomy were screened by including exclusion criteria. The specific criteria are as follows: (1) Postoperative pathological diagnosis: CLM (2) Age ≤ 14 years (3) Absence of severe chest cavity infection (4) Absence of severe adhesions (5) Absence of underdeveloped interlobar fissure (anatomical lobar fissure grading, Grade3, 4), according to proposed anatomical classification of pulmonary fissures¹⁷. Patients were divided into a non-chest tube (NCT)group and a chest tube (CT)group based on whether chest tubes were placed after surgery, as shown in Fig. 1.

Fig. 1.

Screening and follow-up of the participants. The protocol of this study about screening, grouping and follow-up.

Baseline data (age, BMI, sex, pathological type), operation outcomes (blood loss, surgical time), postoperative hospital stay, FLACC scale score¹⁸, postoperative complications and follow-up outcomes were compared between the two groups. All patients were followed up for more than 3 months. All patients underwent low-dose chest computerized tomography scans 1–2 days after surgery. In the CT group, the chest tube was removed according to the imaging examination and drainage conditions. The FLACC scale score was determined on the morning of the first postoperative day.

SPSS 22.0 statistical software was used for all statistical analyses. Continuous variables were presented as mean ± standard deviation (SD) or as median (25th–75th percentile) depending on normality. Differences were evaluated using Student’s t-test for continuous parametric data, the Wilcoxon test for continuous nonparametric data, and Pearson’s chi-squared test for noncontinuous data. p < 0.05 was considered statistically significant.

Results

From January 2014 to January 2023, a total of 869 patients received thoracoscopic lobectomy, according to inclusive and exclusive criteria, a total of 632 patients were enrolled in the study, therein 312 patients did not place chest tube in the NCT group and 320 are included in the CT group. Baseline data are summarized in Table 1. There were no statistically significant differences in age (p = 0.18), BMI (p = 0.1), Sex (p = 0.35), or pathological type between the two groups. The baseline data of the two groups were unified and comparable, as shown in Table 1.

Table 1.

Baseline data of the NCT and CT groups.

	NCT (n = 312)	CT (n = 320)	P
Median age (month)	6 (3–18)	8 (3–29)	0.18
Mean BMI	13.6 ± 2.2	18.1 ± 2.3	0.1
Female	149	141	0.35
Male	163	179
Pathological type
CPAM	206	218	0.59
PS	71	88	0.17
CLE	35	14	0.08

There were no statistically significant differences in the baseline data between two groups.

CPAM congenital pulmonary malformation, PS intralobar pulmonary sequestration, CLE congenital lobar emphysema.

The operation and follow-up outcomes are shown in Table 2. The NCT group and CT groups showed no significant differences in mean intraoperative blood loss (7.5 mL [range, 3–48 mL] vs. 13.5 mL [range, 5–76 mL; p = 0.18) or the mean surgical time of the NCT group (41.5 min [range, 34–111 min] vs. 46.6 min [range, 37–128 min]; p = 0.37). The median length of postoperative hospital stay in the CT group was significantly longer than the NCT group (5 d vs.3 d, p = 0.045). In the CT group, patients usually underwent imaging examination 1–2 days after surgery and then the thoracic drainage tubes were removed; thus, the median chest tube drainage time was 2 days. In the NCT group, the FLACC scale score was 2.7 (range 1.5-5.0), which significantly lower than that in the CT group 5.8 (range 2.5–7.5) (p = 0.027).

Table 2.

Operation and follow-up outcomes.

	NCT (n = 312)	CT (n = 320)	P
Mean Intraoperative blood loss (ml)	7.5 ± 2.7	13.5 ± 3.2	NS*
Mean surgical time (min)	41.5 ± 4.3	46.6 ± 5.6	NS*
Median postoperative hospital stays (day)	3 (2–7)	5 (3–14)	0.041
Median chest tube drainage time (day)	–	2 (1–14)	–
FLACC scale score	2.7 ± 0.43	5.8 ± 0.26	0.027
Postoperative Complications:
Pneumothorax	3	0	NS*
Pleural effusion	6	1	NS*
Infectiona	0	8	0.005
Atelectasis	6	18	0.014
Pneumonia	8	13	NS*
Subcutaneous emphysema	232	57	NS*
Fever	89	76	NS*
Recurrence	0	0
Bronchopleural fistula	0	0
Death	0	0

A: infection related to chest tube.

NS no significance.

The postoperative complications that occurred in the NCT group and CT group were compared as follows: In the NCT group, 3 patients developed pneumothorax after the operation. There were 6(1.9%) patients with pleural effusion in the NCT group and 1(0.3%) patient in CT group (p = 0.053), and 2 patients in the NCT group replaced the chest tube for 2–5 day. treatment. Eight (2.5%) patients developed chest tube-related infections in the CT group(p = 0.004). Six patients developed atelectasis in the NCT group, which was significantly less than the 18 patients in the CT group (p = 0.014). No complications such as bronchopleural fistula, death or recurrence were observed in either group in the follow-up.

Discussion

After postoperative imaging examination, three cases of pneumothorax occurred in the NCT group after postoperative imaging examination, and this symptom was alleviated 3–7 days after placing a chest tube and it was found that there were 6 (1.9%) patients who experienced pleural effusion in the NCT group and 1 (0.3%) patient in the CT group, 3 patients in NCT group replaced the chest tube for 2–5 days, the remaining patients only received conservative and symptomatic treatment and were discharged after recovery. All patients had no serious complications such as bronchopleural fistula, tension pneumothorax, massive bleeding, death, or reoperation. Therefore, we believe that not placing a chest tube after thoracoscopic lung resection in children with CLM has high safety and this is consistent with our previous findings¹⁹.

To ensure postoperative safety and to avoid complications caused by surgical techniques, the following technical points should be met: first, thoracoscopic lobectomy needs to be an anatomical and precise resection, and the structure at the hilum of the lung must be accurately and properly exposed^20–23, as shown in Fig. 2. Second, thoracoscopic lobectomy through the pulmonary hilum approach can effectively exposed the incomplete interlobular fissure¹⁶. Third, the use of thoracoscopic clockwise lobectomy can effectively shorten the operative time and reduce the occurrence of intraoperative and postoperative complications²⁴. At the same time, after removal of diseased lung lobe, a comprehensive examination of air tightness and bleeding is also a very important step. The above measures can ensure the postoperative complications of thoracoscopic lobectomy in children with CLM at a very low level. Finally, even if some common postoperative complications occur, we can detect complications through patient vital signs and postoperative imaging examination, meanwhile, we can effectively resolve most complications by replacing the chest tube.

Fig. 2.

Postoperative lung hilum structure. The pulmonary hilum structure at the end of the surgery. A, B and V represent pulmonary artery, bronchus, pulmonary vein stumps, respectively. RUL right upper lobe, RML right middle lobe.

For the postoperative safety reasons, not all patients who undergo thoracoscopic lobectomy can avoid placing a chest tube. We have established an inclusion and exclusion criteria, which excluded those CLM patients with a high risk of air leakage and bleeding postoperative complications to ensure postoperative safety. First, excluded the patients who have severe chest cavity infection: patients with severe chest infections may have unclear anatomical structures within the chest cavity, resulting in a relatively high incidence of postoperative complications such as pneumothorax and pleural effusion^25,26; Second, excluded the patients who have severe chest cavity adhesions may occur after repeated infections in the chest cavity. Similarly, these patients have difficulty distinguishing the anatomical structure within the chest cavity, making it difficult to separate and expose them²⁷. Finally, excluded the patients who have undeveloped interlobar fissures between the lesion and the adjacent normal lobar lobe. Especially in cases with anatomical lobar fissure grading (Grade 3 or 4), a large lung tissue section would be left on the normal lobar lobe after resection, which accordingly has the risk of postoperative air leakage, bleeding, and exudation^16,28,29. For cases with anatomical lobar fissure grading Grade 1 and 2, using an energy platform can effectively cut and close the cross-section. Therefore, these kinds of patients are required to install a chest tube after surgery.

In addition to safety, we evaluated the effectiveness of not installing a chest tube, the median length of postoperative hospital stay in the NCT group was shorter than that in the CT group. Eight (2.5%) patients developed chest tube-related infections in the CT group. Among these 8 cases, 6 patients developed infection at the skin of the drainage tube and recovered after local disinfection treatment, two cases of intrathoracic infection were treated with intravenous antibiotics therapy. Six patients developed atelectasis in the NCT group, which was significantly less than the 18 patients in the CT group. We speculate on the possible causes of this phenomenon that the patient was young and unable to cooperate with postoperative respiratory rehabilitation training, additionally, due to the pain and discomfort caused by the thoracic drainage tube, the patient’s sputum excretion ability decreased, leading to bronchial obstruction and resulting in atelectasis. The postoperative pain caused by the drainage tube is also an important factor affecting the postoperative recovery of patients³⁰. This study used the FLACC scale score for pain assessment in pediatric patients¹⁸. The FLACC scale score was performed in the morning of the first postoperative day. In the NCT group, the FLACC scale score was significantly lower than that in the CT group. In summary, no chest tube placing after thoracoscopic lobectomy is effective in shortening the hospital stay, reducing the incidence of postoperative complications and postoperative pain for pediatric CLM patients.

There are some limitations to this study. It is a retrospective study, so the two groups were unable to achieve optimal baseline alignment. This study included data from 4 pediatric surgery institutions, although all centers have completed the learning curve for pediatric thoracoscopic lobectomy, most patients in the NCT group were distributed in the one institution, for postoperative care and data recording which inevitably exist variability. Therefore, the next step of this study requires a prospective study is needed to provide more reliable evidence.

In brief, when pediatric CLM patients without severe infection, pleural adhesions, and well-developed interlobular fissures undergo thoracoscopic lobectomy, it may be safe and feasible not to place a chest tube after surgery if the anatomical structure is accurately operated during the surgery, which may effectively avoid complications related to the drainage tube and facilitate rapid recovery.

Author contributions

Kaisheng Cheng: conceptualization, data collection and investigation, writing original draft, writing—review and editing; Miao Yuan&Gang Yang: methodology, conceptualization, formal analysis; Taozhen He and DengKe Luo: software, formal analysis and draft revision; Chenyu Liu and ZongYu Wang: contributed to the methodology, writing and data curation; Jiayin Yang: writing, review and editing, supervision; Fei Li, Guangxian Yang&Yonggang Li: Resources, investigation, data curation; Chang Xu: validation, data curation, project administration, Funding acquisition.

Funding

This work was supported by Sichuan Provincial Department of Science and Technology Project [grant numbers No. 2022NSFSC0354].

Data availability

The data supporting the findings of this study are available within the article.

Declarations

Competing interests

The authors declare no competing interests.

Statement of informed consent

Informed consent was obtained from all individual participants included in the study.

Ethics approval

This study was approved by the Institutional Review Board and Ethical Committee of West China Hospital of Sichuan University in China (No.1284).