Gen Thorac Cardiovasc Surg
DOI 10.1007/s11748-016-0692-6
ORIGINAL ARTICLE
Thoracoscopic pulmonary wedge resection without post-operative
chest drain: an observational study
Bo Laksáfoss Holbek1,2 • Henrik Jessen Hansen1 • Henrik Kehlet2
René Horsleben Petersen1
Received: 10 June 2016 / Accepted: 20 July 2016
Ó The Japanese Association for Thoracic Surgery 2016
Abstract
Objective Chest drains are used routinely after wedge
resection by video-assisted thoracoscopic surgery (VATS),
although this practice is based largely on tradition rather
than evidence. Chest drains may furthermore cause pain,
infections, and prolonged length of stay. The aim of this
prospective observational study was to assess the feasibility
of avoiding chest drains following VATS wedge resection
for pulmonary nodules.
Methods Between 1 February and 25 August 2015 166 con-
secutive patients planned for VATS wedge resection of pul-
monary nodules were screened for inclusion using the
following criteria: Forced expiratory volume in 1 s (FEV1)
C60 % of expected, FEV1/forced vital capacity C70 %,
tumour diameter B2 cm, distance from tumour to visceral
pleura B3 cm, B2 separate wedges, no air leak on an intra-
operative air leakage test and absence of severe adhesions,
bullous/emphysematous disease, pleural effusion and coagu-
lopathy. Chest X-rays were done twice on the day of surgery.
30-day complications were compiled from patient records.
Results 49 patients underwent 51 unilateral VATS wedge
resections without using a post-operative chest drain. No
patient required reinsertion of a chest drain. 30 (59 %)
patients had a pneumothorax of mean size 12 ± 12 mm on
supine 8-h post-operative X-ray for which the majority
& Bo Laksáfoss Holbek
bo.laksafoss.holbek@regionh.dk
1
Department of Cardiothoracic Surgery, Copenhagen
University Hospital, Rigshospitalet, Blegdamsvej 9,
2100 Copenhagen, Denmark
2
Section for Surgical Pathophysiology, Copenhagen
University Hospital, Rigshospitalet, Blegdamsvej 9,
2100 Copenhagen, Denmark
•
resolved spontaneously within 2-week control. There were
no complications on 30-day follow-up. Median length of
stay was 1 day.
Conclusions The results support that VATS wedge resec-
tion for pulmonary nodules without a post-operative chest
drain may be safe in a selected group of patients.
Keywords Chest tubes
Thoracic surgery
Video-
assisted
Morbidity
Postoperative care/methods
Lung
neoplasms/surgery
Introduction
Chest drains are traditionally used in thoracic surgery to
drain and monitor air leak and fluid accumulation. There
are, however, well known adverse effects with the use of
chest drains such as pain, delayed recovery of pulmonary
function, increased risk of infectious complications such as
pneumonia or empyema, and prolonged length of stay
(LOS) [1–3]. The advances in equipment and surgical
technique seem to have reduced the rate of post-operative
events requiring chest drainage, and indications for post-
operative chest drains might be influenced more by surgical
tradition than up-to-date evidence. Preliminary studies
have described omission of chest drains after both minor
and major lung resection [4–6]. These studies are charac-
terized by being retrospective [4], mainly focused on
benign disease [5], or concerning larger anatomic pul-
monary resection [6].
Objective
The aim of this prospective observational study was to
assess the feasibility and surgical outcome, including the
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rate of complications, of VATS wedge resections for sus-
pected malignant pulmonary nodules treated without a
post-operative chest drain.
Methods
Patient selection
Patients undergoing planned, consecutive VATS wedge
resection for pulmonary nodules suspicious of malignancy
in the time period between 1 February and 25 August 2015
were screened for eligibility for chest drain omission.
Inclusion criteria were as follows: Forced expiratory vol-
ume in 1 s (FEV1) C60 % of expected, FEV1/forced vital
capacity C70 %, tumour diameter B2 cm, distance from
tumour to visceral pleura B3 cm, B2 separate wedges, no
air leak on an intraoperative air leakage test and absence of
severe adhesions, bullous/emphysematous disease, pleural
effusion and coagulopathy (Table 1). Due to logistic rea-
sons patients undergoing frozen section with the aim of a
possible completion lobectomy during the same anaesthe-
sia were not included in the study.
Surgical management
Patients were planned for diagnostic VATS wedge resec-
tion when they had a history of extra-pulmonary primary
cancer and pulmonary nodules that showed signs of
malignancy on imaging, but biopsy attempts had failed. In
some cases a combined diagnostic and therapeutic VATS
wedge resection is possible. Cases with a histologic diag-
nosis of primary lung cancer are subsequently evaluated for
VATS completion lobectomy [7, 8].
Table 1 Inclusion criteria for post-operative chest drain omission
Inclusion criteria for post-operative chest drain omission
Pulmonary VATS wedge resection
Age C18 years
Speak and understand Danish
FEV1 C60 % of expected
FEV1/FVC C70 %
Tumour diameter B2 cm in diameter
Distance from tumour to visceral pleura B3 cm
B2 separate wedge resections
No air leak on intraoperative air leakage test
Adhesions of B30 % of lung surface
Absence of bullous/emphysematous disease
Absence of drainage required plural effusion
Absence of coagulopathy
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Gen Thorac Cardiovasc Surg
Patients were operated under general anaesthesia with
single lung ventilation, using double lumen intubation or
single lumen intubation with bronchial blockade. Surgical
access was established via a standardized anterior approach
using a utility incision of 2–4 cm anteriorly to the latis-
simus dorsi at the 4th–5th intercostal space with two
additional 1–1.5 cm ports placed level with the diaphrag-
matic cupula under thoracoscopic inspection [9, 10]. Local
anaesthetic comprised of 20 mL Marcaine 0.5 % and was
administered either as an intercostal block at the port holes
or as an intraoperative paravertebral block. The nodules
were resected using an EndoGIA Tri-stapler (Covidien,
USA). Upon completion of the procedure, patients meeting
the inclusion criteria had an air leakage test conducted in
the following manner: A standard Ch. 28 chest drain
(ConvaTec, UK) was placed apically through the camera
port, ventilation was shifted to double lung ventilation and
the expansion of the lung was observed thoracoscopically
through the utility incision. The chest drain was fixed by
drain sutures and the tip was kept under water during
continuous double lung ventilation while the remaining
holes were closed. The maximum inspiratory pressure was
20 cmH2O. The drain tip was inspected for air leak for at
least 5 min after closure of all ports. If an air leak indicated
by continuous production of bubbles was present, the
patient received standard treatment with a post-operative
chest drain connected to a digital suction device (Thopaz?,
Medela AG, Switzerland). If the air leak ceased within the
observation period, the chest drain was removed while
keeping a positive inspiratory pressure.
Postoperative management
All patients were referred to a post-anaesthesia care unit
(PACU) for 2–3 h initial observation by trained PACU
nurses. Patients had two post-operative chest X-rays done;
a supine X-ray 1–2 h after surgery and a standing X-ray 8 h
after surgery. Further X-rays during admission were per-
formed only on indication. All patients received analgesic
treatment with paracetamol 1 g 4 times daily and sustained
release ibuprofen 800 mg twice daily.
Patients were scored before discharge from PACU using
recommendations from Danish Society for Anaesthesiol-
ogy and Intensive Care Medicine [11], and admitted to a
standard general thoracic surgical ward. Standard obser-
vations included heart rate, blood pressure, respiratory rate,
temperature and oxygenation at least at 12 h intervals
beginning 1 h after admission. Approximately 2 weeks
after surgery, patients had a follow-up visit in the outpa-
tient clinic with a clinical and radiological post-operative
control. Indications for pleural drainage were symptomatic
pneumothorax, expanding pneumothorax, hemothorax, or
expanding subcutaneous emphysema.
Gen Thorac Cardiovasc Surg
Data recorded
Baseline variables include age, weight, height, smoking
history, lung function, tumour size(s), distance from inner
margin of tumour to visceral pleura, and comorbidities.
Surgical data included operative time, surgeon, number of
staples, number of resections, time to mobilization, size of
postoperative pneumothorax on X-ray measured as the
vertical distance between the apex of the lung and the top
of the thoracic cavity, and LOS. Complications were doc-
umented both upon discharge and in the outpatient clinic
using a standardized form for all patients in our clinic. A
structured telephone interview was carried out after POD
30. Patient records and telephone interviews were reviewed
for any adverse events related to their lung surgery. Using
these data, 30-day complications were compiled.
Statistical analysis
Continuous variables are presented as mean ± standard
deviation (SD) or as median (25th–75th percentile)
depending on normality. Categorical variables are pre-
sented as number (percentage). Comparison between
groups for continuous non-normal data has been performed
using Mann–Whitney U test and Student’s t test according
to normality. All statistical analyses have been performed
using SPSS 22.0 (IBM SPSS Statistics, Chicago, USA).
Results
In the study period 166 patients planned for VATS wedge
resections were screened for eligibility to join the study. Of
these, inclusion criteria were fulfilled in 51 procedures and
the chest drain was, therefore, removed in the operating
room. Two patients underwent secondary contralateral
resection during the study period; a total of 49 patients
underwent the above mentioned 51 procedures. No patient
underwent bilateral simultaneous wedge resection.
Of the 115 procedures excluded from the study, 78
patients were excluded preoperatively due to lung function
criteria (n = 49), tumour characteristics (n = 12), both
lung function criteria and tumour characteristics (n = 9),
insufficient lung function measurements (n = 3), inability
to give consent to data collection (n = 3), or coagulopathy
due to not having paused anticoagulation therapy (n = 2).
The remaining 37 patients had a chest drain placed due to
continuous air leakage (n = 13), major adhesions (n = 4),
[2 separate resections (n = 3), lymph node dissection
(n = 2), surgical habit (n = 6), surgeon’s preference due
to problematic procedure (n = 5), and increased risk of air
leak due to either electrocautery dissection in the fissure
(n = 3) or iatrogenic trauma to the lung parenchyma that
had to be hand sewn (n = 1). No patients were excluded
because of bullous/emphysematous disease. A flowchart of
inclusion of cases is described in Fig. 1.
Patient characteristics are summarized in Table 2. Mean
age was 64 ± 13 years and 10 % were smokers or had quit
within the previous 6 months. Mean FEV1 was
103 ± 15 % of expected and mean FEV1/FVC was
79 ± 5 %.
Operative outcome is summarized in Table 3. Median
duration of procedure was 36 (29–42) min. The procedures
were performed by 11 different surgeons, with only 9
procedures being performed by consultants. In 30 (59 %)
cases there was a minor postoperative pneumothorax api-
cally with a mean size of 12 ± 12 mm. One patient had a
pneumothorax of 6.6 cm and stayed an extra day for
observation until being discharged on POD 2 after a
marked radiologic improvement, and showed complete
expansion of the lung on in the outpatient clinic. Except for
three patients, all pneumothoraxes had resolved sponta-
neously on post-operative control 2 weeks after surgery.
The three pneumothoraxes were minor and clinically
insignificant with a mean size of 6 ± 4 mm apically. No
patients had clinical or radiologic signs of haemorrhage.
There were no patients requiring chest drain insertion due
to any cause, including pneumothorax, subcutaneous
emphysema or haemorrhage during the 30-day follow-up
period.
Final pathology is summarized in Table 4. Mean tumour
size was 9 ± 4 mm with a mean distance of 11 ± 5 mm
from the visceral pleura. Malignancy was found in 46 cases
among which 4 (8 %) were non-small cell lung cancer
(NSCLC), and 42 (82 %) were metastases. Three cases
with NSCLC underwent subsequent VATS completion
lobectomy, while the remaining one was not deemed
operable due to competing disseminated malignancy.
Discussion
Post-operative management without a chest drain may
diminish morbidity and enhance recovery. Furthermore, it
may support the benefit of minimally invasive surgery
which opens up for the possibility of outpatient surgery
[12]. In this study, we managed to remove the chest drain
intraoperatively in 51 patients undergoing VATS wedge
resection. Patients were included and followed prospec-
tively until POD 30. During this period there were no
complications due to the avoidance of a post-operative
chest drain, and notably no patient had a chest drain
inserted post-operatively. In several patients a minor
pneumothorax was revealed on post-operative X-ray,
however, patients were asymptomatic and this finding had,
therefore, no clinical impact. In one patient, however, a
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 Gen Thorac Cardiovasc Surg

Fig. 1 Patient inclusion.

Flowchart of patient selection

Table 2 Patient characteristics Table 3 Operative outcome

N = 49 N = 51

Age 64 ± 13 years Operative time 36 (29–42) min

BMI 27.2 ± 4.5 kg/m2 Number of staples used per procedure 3 (2–4)
Smokers 5 (10) Procedures with 2 resections 8 (16)
Pack years 3 (0–17) Time to mobilization 3 (1–4) h
FEV1 2.9 ± 0.8 L Patients with pneumothorax on 8 h X-ray 30 (59)
FEV1 percentage of expected 103 ± 15 % Size of pneumothorax on 8 h X-ray 12 ± 12 mm
FVC 3.7 ± 1.0 L LOS 1 (1–2) days
FVC percentage of expected 106 ± 16 % Patients requiring post-operative chest drainage 0
FEV1/FVC 79 ± 5 % Patients with any 30-day surgical complication 0
DLCOc SB 7.5 ± 2.0 mmol/min/kPa Values are expressed as mean ± standard deviation, median (25th–
DLCOc SB percentage of expected 85 ± 15 % 75th percentile), or number (%)
Values are expressed as mean ± standard deviation, median (25th– LOS length of stay, h hour(s)
75th percentile), or number (%)
BMI body mass index, FEV1 forced expiratory volume in 1 s, FVC In this study, we showed that using standardized criteria,
forced vital capacity, DLCOc SB diffusion capacity of the lung for patients undergoing VATS wedge resection can be treated
carbon monoxide, single breath, adjusted for haemoglobin without using a post-operative chest drain. Due to the high
selection, however, a relatively small proportion of the
large apical pneumothorax meant an extra day of admis- total patients were eligible for treatment without a chest
sion, although no surgical intervention was indicated since drain (51/166). Nonetheless these criteria benefit patients
the pneumothorax was completely resolved on 2 week by successfully avoiding post-operative complications on
post-operative control. It is likely that some residual air 30-day follow-up, thus providing the surgeon with a safe
may have remained in the pleura after the intraoperative air alternative to routine use of a post-operative chest drain.
leakage test, possibly due to inadequate positioning of the The high selection probably explains why no patients had
drain. bullous/emphysematous disease.

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Gen Thorac Cardiovasc Surg
Table 4 Pathology
N = 51
Tumour diameter 9 ± 4 mm
Tumour distance to pleura 11 ± 5 mm
Non-small cell lung cancer 4 (8)
Metastasis 42 (82)
Benign 5 (10)
Values are expressed as mean ± standard deviation, or number (%)
Given the observational nature, this study does not
permit evaluation of the possible benefits in pain and LOS.
A few patients, however, who had previously undergone
VATS surgery with subsequent post-operative chest drain,
reported a subjective reduction in pain in this study. This is
in accordance with a study by Refai et al. showing an
analgesic benefit in removing a chest drain [2]. These
results need to be confirmed in prospective randomized
studies.
In 2011 consensus guidelines on the management of
chest drains were formed in collaboration by the European
Society of Thoracic Surgeons, the American Association
for Thoracic Surgery, the Society of Thoracic Surgeons,
and the General Thoracic Surgery Club [13]. Omission of
post-operative chest drains is, however, not discussed. A
few preliminary studies have described the early removal
of chest drains after pulmonary resection [5, 6, 14–16]. In
1998 Russo et al. described the early removal of chest
drains within 90 min of surgery in 31 of 33 patients after
VATS wedge resection for pulmonary nodules or intersti-
tial lung disease. The study demonstrated shorter LOS and
similar complications in the early chest drain removal
group compared to patients treated with a chest drain [14].
In 2006 Fibla et al. described early chest drain removal
within 60 min of VATS lung biopsy in 135 out of 160
patients, allowing for outpatient surgery in some cases
[15]. A randomized controlled trial (RCT) of 60 patients
undergoing VATS wedge resection by Luckraz et al.
demonstrated removal of pleural drainage already in the
operating theatre with a median LOS of 1 day versus 3 in
favour of the no-drain group without higher rates of com-
plications [5]. Patients in the study had, however, mainly
benign disease providing low generalizability in the treat-
ment of malignant disease. A retrospective study by
Nakashima et al. from 2009 of 333 patients undergoing
thoracoscopic wedge resections among whom 132 patients
were managed with intraoperative chest drain removal,
showed a shorter LOS in the no-drain group [16]. Omission
of chest drain has even been described after major lung
resection in 21 of 50 patients undergoing VATS segmen-
tectomy or lobectomy in a study from 2012 by Ueda and
colleagues [6]. However, previous studies are mainly
retrospective or limited to benign disease, and exact fol-
low-up safety data on studies of chest drain omission are
limited.
The inspiratory pressure might affect the result of the air
leakage test. In this study, we used an inspiratory pressure
of 20 cm H2O based on current practice in our institution
when expanding the lung. Keeping a lower maximum
inspiratory pressure, air leakage might be further dimin-
ished, although it might compromise complete lung
expansion. Nakashima et al. [16] used a maximal inspira-
tory pressures of 15 cm H2O to determine an air leak, and
then repeated the test at 10 cm H2O if no initial air leak
was found. The authors concluded that the adequate pres-
sure range may be 15–20 cm H2O to prevent atelectasis
and avoid injury to the lung parenchyma and staple line.
Ueda et al. [6], described a modification of the air leakage
test using an inspiratory pressure of 10 cm H2O while
applying a simultaneous suction of 5 cm H2O to the chest
drain, but without further details. The optimal inspiratory
pressure when performing an air leakage test is yet to be
determined.
The indication to drain a pneumothorax depends on
clinical and radiological observations. Previously the rate
of reinsertion of a chest drain in patients having undergone
intraoperative chest drain removal is reported to be
1.1–2.3 % [16, 17], however, as expressed by Nakashima
et al. there may be a learning curve, since these incidences
occurred in the early cases of intraoperative chest drain
removal where 2 out of the 3 cases were caused by tech-
nical failure [16]. As concluded in a study by Cerfolio
et al., a non-symptomatic pneumothorax may not neces-
sarily require a chest drain [18]. In this study, we found a
minor non-symptomatic pneumothorax in 30 patients with
mean size of 12 mm that required no further intervention
during the 30 day observation period and for the majority
resolved spontaneously, thus supporting earlier findings.
Limitations
The patients were highly selected, since the focus by our
team was to ensure safety. The study was performed in a
high volume centre with more than 80 % of procedures
performed as VATS, and data might not be reproducible in a
smaller less subspecialized unit. Finally it is a small sample
size and safety data need to be confirmed in larger studies.
Conclusion
This feasibility study showed that omission of a chest drain
after VATS wedge resection for pulmonary nodules may be
safe in selected patients.
123

Acknowledgments The authors thank Kirstine Hartmann Johansen
(Research nurse, Department of Cardiothoracic Surgery, Copenhagen
University Hospital Rigshospitalet, Copenhagen, Denmark) for data
collection.
Compliance with ethical standards
The study was approved by the data protection agency and all patients
gave their consent to data collection. This prospective observational
study did not require approval from an institutional review board.
Conflict of interest Dr. Bo Laksáfoss Holbek received a grant from
Medela AG during the conduct of the study. Dr. Henrik Jessen
Hansen reports personal fees from Covidien, Medela, and Bard. Dr.
René Horsleben Petersen reports personal fees from Covidien,
Medela, and Takeda outside the submitted work. Professor Henrik
Kehlet has no conflict of interest.
References
1. Mao M, Hughes R, Papadimos TJ, Stawicki SP. Complications of
chest tubes: a focused clinical synopsis. Curr Opin Pulm Med.
2015;21:376–86.
2. Refai M, Brunelli A, Salati M, Xiumè F, Pompili C, Sabbatini A.
The impact of chest tube removal on pain and pulmonary func-
tion after pulmonary resection. Eur J Cardiothorac Surg.
2012;41:820–2 (discussion 823).
3. Bardell T, Petsikas D. What keeps postpulmonary resection
patients in hospital? Can Respir J. 2003;10:86–9.
4. Watanabe A, Watanabe T, Ohsawa H, Mawatari T, Ichimiya Y,
Takahashi N, et al. Avoiding chest tube placement after video-
assisted thoracoscopic wedge resection of the lung. Eur J Car-
diothorac Surg. 2004;25:872–6.
5. Luckraz H, Rammohan KS, Phillips M, Abel R, Karthikeyan S,
Kulatilake NEP, et al. Is an intercostal chest drain necessary after
video-assisted thoracoscopic (VATS) lung biopsy? Ann Thorac
Surg. 2007;84:237–9.
6. Ueda K, Hayashi M, Tanaka T, Hamano K. Omitting chest tube
drainage after thoracoscopic major lung resection. Eur J Car-
diothorac Surg. 2013;44:225–9.
7. Holbek BL, Petersen RH, Hansen HJ. Is it safe to perform
completion lobectomy after diagnostic wedge resection using
123
Gen Thorac Cardiovasc Surg
video-assisted thoracoscopic surgery? Gen Thorac Cardiovasc
Surg. 2016;64:203–8.
8. Callister MEJ, Baldwin DR. How should pulmonary nodules be
optimally investigated and managed? Lung Cancer.
2016;91:48–55.
9. Hansen HJ, Petersen RH, Christensen M. Video-assisted thora-
coscopic surgery (VATS) lobectomy using a standardized ante-
rior approach. Surg Endosc. 2011;25:1263–9.
10. Hansen HJ, Petersen RH. Video-assisted thoracoscopic lobec-
tomy using a standardized three-port anterior approach—the
Copenhagen experience. Ann Cardiothorac Surg. 2012;1:70–6.
11. DASAIM. DASAIM’S rekommandation for udskrivningskriterier
fra anæstesiologisk observationsafsnit [Internet]; 2016. http://
www.dasaim.dk/wp-content/uploads/2016/03/Udskrivningskri
terier-2016.pdf.
12. Holbek BL, Petersen RH, Kehlet H, Hansen HJ. Fast-track video-
assisted thoracoscopic surgery: future challenges. Scand Cardio-
vasc J. 2016;50:78–82.
13. Brunelli A, Beretta E, Cassivi SD, Cerfolio RJ, Detterbeck F,
Kiefer T, et al. Consensus definitions to promote an evidence-
based approach to management of the pleural space. A collabo-
rative proposal by ESTS, AATS, STS, and GTSC. Eur J Car-
diothorac Surg. 2011;40:291–7.
14. Russo L, Wiechmann RJ, Magovern JA, Szydlowski GW, Mack
MJ, Naunheim KS, et al. Early chest tube removal after video-
assisted thoracoscopic wedge resection of the lung. Ann Thorac
Surg. 1998;66:1751–4.
15. Fibla JJ, Molins L, Pérez J, Vidal G. Early removal of chest
drainage and outpatient program after videothoracoscopic lung
biopsy. Eur J Cardiothorac Surg. 2006;29:639–40.
16. Nakashima S, Watanabe A, Mishina T, Obama T, Mawatari T,
Higami T. Feasibility and safety of postoperative management
without chest tube placement after thoracoscopic wedge resection
of the lung. Surg Today. 2011;41:774–9.
17. Satherley LK, Luckraz H, Rammohan KS, Phillips M, Kulatilake
NEP, O’Keefe PA. Routine placement of an intercostal chest
drain during video-assisted thoracoscopic surgical lung biopsy
unnecessarily prolongs in-hospital length of stay in selected
patients. Eur J Cardiothorac Surg. 2009;36:737–40.
18. Cerfolio RJ, Minnich DJ, Bryant AS. The removal of chest tubes
despite an air leak or a pneumothorax. Ann Thorac Surg.
2009;87:1690–6.