Standardization of intra- and peri-operative management to reduce postoperative drainage time after major thoracoscopic pulmonary resections.

Background: It is important to reduce the postoperative drainage time after thoracic surgery to relieve postoperative pain and facilitate patient mobilization. We standardized intra- and peri-operative management of major, thoracoscopic pulmonary resections in February 2019. In this study, we investigated whether this standardization reduced the postoperative drainage time. Moreover, we examined how such management affected re-admission within 30 days after operation (because of pleural complications).

Methods: Between May 2012 and February 2022, 815 patients with malignant or benign disease underwent major thoracoscopic pulmonary resections in our department. The patients were classified into two groups: those who received standardized management (n=352) and those who did not (n=463). After propensity score-matching, we compared characteristics and perioperative results between the two groups (n=234 in each group) by univariate analysis. The factors affecting postoperative drainage time and re-admission within 30 days after operation (because of pleural complications) were evaluated via multivariate analysis. Standardized management was as follows: (I) intraoperatively, any dense fissures were left untreated to avoid postoperative air leakage. A fissureless or unidirectional dissection technique served as an alternative; pulmonary vessels and bronchi were divided at the hilum in patients with dense fissures. (II) The chest drain was removed when air leakage ceased, regardless of the fluid volume or surgeon's preference.

Results: The standardized management group evidenced superior results in terms of operative time (P<0.0001) and postoperative drainage time (P<0.0001). There were no significant differences in the remaining perioperative parameters. Moreover, standardized management significantly reduced postoperative drainage time, as revealed by multivariate analysis [estimated regression coefficient: -0.47; 95% confidence interval (CI): -0.78 to -0.16; P=0.003]. Moreover, standardized management did not significantly increase re-admission (because of pleural complications) [odds ratio (OR) =1.76; 95% CI: 0.557 to 5.58; P=0.34].

Conclusions: Standardized intra- and peri-operative management significantly reduced the postoperative drainage time after major thoracoscopic pulmonary resections, without increasing re-admissions within 30 days among patients with pleural complications caused by insufficient drainage. Surgeons must master a fissureless or a unidirectional dissection technique, avoid dissection of fused fissures, and apply standardized perioperative drainage management.