Enhanced recovery in lung surgery: coaxial versus conventional chest drains following video-assisted thoracoscopic surgery lobectomy—a prospective randomized trial

Introduction

Effective postoperative drainage remains a cornerstone in thoracic surgery, particularly following pulmonary resections such as lobectomies. Proper evacuation of air, blood, and other fluids from the pleural cavity is essential to ensure lung re-expansion and to prevent postoperative complications such as pneumothorax, hemothorax, subcutaneous emphysema, and empyema (1). While chest tube drainage has been a routine practice for over a century, the optimal type, number, and configuration of chest drains are still debated (2).

The principle of closed chest tube drainage was first introduced in 1875 by Gotthard Bülau, laying the foundation for modern thoracic drainage practices. Despite advancements in surgical techniques and postoperative care, there remains no consensus on the ideal drainage system following major thoracic procedures. With the evolution of minimally invasive approaches and Enhanced Recovery After Surgery (ERAS) protocols, there has been a paradigm shift toward using a single chest tube, which is thought to minimize patient discomfort and facilitate faster recovery (3).

Conventional single-lumen chest drains, often made of silicone or polyvinylchlorid (PVC) and inserted in a posterior or apical position, are widely used for their simplicity. However, they are prone to occlusion, especially in the presence of viscous or blood-rich fluid, and may be inadequate for efficient air evacuation in cases of persistent leaks (4). These limitations can lead to retained blood syndrome (RBS), increased inflammation, and prolonged hospital stays (5,6).

To address these issues, coaxial drainage systems have been introduced. These drains consist of an inner lumen dedicated to air evacuation and external longitudinal grooves or channels that allow simultaneous fluid removal. Theoretically, this design reduces the risk of clogging and improves separation of air and fluid flows. Initial studies suggest that coaxial drains are associated with shorter hospitalization and decreased analgesic drugs (7,8).

Despite these promising findings, comparative evidence between coaxial and conventional drainage systems remains limited. Objective outcome measures such as air leak rate, fluid output, inflammatory markers like C-reactive protein (CRP), and chest tube duration have not been uniformly studied across drainage types.

This prospective randomized study aims to compare the clinical performance of conventional and coaxial thoracic drainage systems in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC). By evaluating drainage efficiency, complication rates, and inflammatory response, the study seeks to determine whether coaxial systems offer a measurable advantage in standard thoracic surgical care. Given the clinical impact of chest tube-related complications on hospital stay, patient morbidity, and resource utilization, this analysis is timely and clinically relevant. We present this article in accordance with the CONSORT reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1169/rc).

Methods

Study design

This was a prospective, randomized clinical trial conducted at the Department of Thoracic Surgery, Otto-Wagner Hospital/Clinic Floridsdorf Vienna. The study aimed to compare the effectiveness of conventional and coaxial chest drainage systems following VATS lobectomy for NSCLC. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Vienna (No. EK20-081-6020) and informed consent was taken from all the patients. The clinical trial was registered under the number NCT04778826.

This drainage study was conducted as a nested randomization sub-study within the broader trial framework investigating the bilateral lymphadenectomy via video-assistierte mediastinoskopische lymphadenektomie (VAMLA) versus unilateral mediastinal lymph node dissection (MLND) in patients undergoing VATS lobectomy. All patients enrolled in the parent trial were subsequently randomized in a second step to receive either a conventional (single-lumen silicone Blake) or a coaxial (dual-channel) chest drain.

The primary endpoint of the current analysis was the duration of chest tube drainage (in days), chosen for its clinical relevance to postoperative recovery and hospital discharge timing. A sample size calculation was performed using G*Power (version 3.1.9.7), based on preliminary institutional data with a power of 80% at a two-tailed alpha of 0.05 and revealed that the minimum sample size required was 128 patients per group. To allow for dropouts or missing data, 150 patients were enrolled per group, totaling 300 patients in the final analysis.

Randomization was conducted using a computer-generated sequence (https://www.randomizer.at/) and implemented via sealed, opaque, and sequentially numbered envelopes. Allocation concealment was maintained by a study coordinator independent of patient care. Block randomization (block size =10) was used to ensure balanced group sizes throughout the enrollment period. No additional stratification factors were applied during randomization.

Study population

A total of 311 patients diagnosed with NSCLC (stages I–IIIA) were included between 2020 and 2022 after multidisciplinary tumor board evaluation recommending primary surgery without neoadjuvant therapy. All patients underwent VATS lobectomy and systematic MLND as per European Society of Thoracic Surgeons (ESTS) guidelines. Patients converted to thoracotomy intraoperatively were excluded from the analysis (n=11, Figure 1 and Table 1).

Figure 1 Flow diagram of the progress through the phases of a parallel randomised trial. VATS, video-assisted thoracoscopic surgery.

Surgical technique and drain allocation

A standardized surgical approach was employed for all patients undergoing VATS lobectomy. The procedure was performed through a 4–5 cm anterior incision at the fourth intercostal space, protected by a soft tissue retractor (Alexis^®). In selected cases, an auxiliary camera port was used to enhance visualization. All surgeons followed an identical fissure-last technique, utilizing LigaSure^TM for tissue dissection and endoscopic staplers for bronchovascular structures and fissure division. Although the operations were performed by different board-certified thoracic surgeons according to the institutional surgery schedule, the same instruments, devices, and technique were applied in all cases to maintain procedural consistency.

At the end of surgery, patients were randomly assigned in a 1:1 ratio to receive either a conventional tube (CT) group (n=150; single 24-French silicone Blake drain) or a coaxial drain (CD) group (n=150; single 24-French coaxial drain with a central air channel and peripheral fluid grooves). No additional chest tubes, suction drains, or alternative forms of pleural drainage were used in any of the included patients. The drain was inserted through the utility incision and positioned dorsally and apically. It was then connected to a digital closed suction system (Thopaz^TM, Medela) with a preset suction level of −20 mmHg. After confirming full lung re-expansion and adequate air evacuation, the chest cavity was closed, and all patients were extubated in the operating room (Figure 1).

Postoperative management

Patients were transferred to the intermediate care unit postoperatively. Digital monitoring continuously recorded air flow (mL/min) and fluid output (mL/day). Routine upright chest radiography was performed on postoperative day (POD) 2. Chest tubes were removed when the air flow reached 0 mL/min for ≥4 hours and fluid drainage decreased to <5 mL/kg in 24 hours. Patients were typically discharged the day after chest tube removal following radiological confirmation of full lung expansion.

Data collection

Clinical data were retrieved from patient records and subsequently anonymized for analysis. The collected variables included demographic information, surgical characteristics such as the resected pulmonary lobe (right or left upper, middle, or lower lobe), postoperative inflammatory markers and drainage metrics. These metrics encompassed the daily volume of pleural fluid evacuated over the first ten PODs, the rate of air leak (measured in mL/min), the presence of subcutaneous emphysema, the occurrence of drain occlusion, and the total duration of drainage in days. Air leakage was defined as a persistent airflow greater than 100 mL/min. To evaluate drainage performance under varying clinical conditions, patients were stratified based on the presence or absence of significant air leakage.

Statistical analysis

All statistical analyses were conducted using SPSS for Windows, Version 21 (IBM Corp., Armonk, NY, USA). Descriptive data were presented as means with standard deviations (SDs) for continuous variables and as frequencies with percentages for categorical variables. Comparative analyses between groups were performed using the Chi-squared (χ²) test for categorical data, the independent-samples t-test or one-way analysis of variance (ANOVA) with Tukey’s post-hoc test for normally distributed continuous variables, and the Mann-Whitney U test for non-normally distributed variables. Repeated measures ANOVA was applied to assess longitudinal trends in drainage volume and air leak flow. To determine the independent effects of clinical variables on drainage duration, a multiple logistic regression analysis was carried out with adjustment for potential confounders. Correlations between continuous parameters were evaluated using Spearman’s rank correlation coefficient. Statistical significance was established at a threshold of P<0.05.

Results

Patient demographics and surgical characteristics

The study cohort comprised 300 patients who underwent pulmonary lobectomy for bronchial carcinoma. The mean age was 59±12 years, with a predominance of male patients (n=173; 57.7%). Surgical resections involved various lobes, with the right upper lobe being the most frequently removed (n=118; 39.4%), followed by the left upper lobe (n=108; 36%), right lower lobe (n=34; 11.3%), left lower lobe (n=19; 6.3%), and the middle lobe (n=21; 7%).

Drainage duration and postoperative output

The mean duration of drainage was significantly longer in the CT group (6.0±3.0 days) compared to the CD group (4.0±2.0 days, P=0.04). Over the first 5 PODs, there was a consistent decline in daily fluid output, from 608.0±398.0 mL on the day of surgery to 305.0±240.0 mL by POD 5 in patients with conventional tube (CT) and from 508.0±282.0 mL on the day of surgery to 292.0±146.0 mL by POD 5 in patients with coaxial drainage (P<0.001, repeated measures ANOVA, Figure 2). However, neither total fluid volume did significantly differ between the groups (P=0.46), nor did the average air flow (P=0.48), indicating comparable baseline performance (Figure 3).

Figure 2 Trend of daily pleural fluid output over the first 5 PODs in patients undergoing VATS lobectomy. Mean fluid volume (± standard deviation) decreased significantly over the POD (P<0.001, repeated measures ANOVA). ANOVA, analysis of variance; OP, operation; POD, postoperative day; VATS, video-assisted thoracoscopic surgery.

Figure 3 Trend of daily of mean air flow over the first 5 PODs in patients undergoing VATS lobectomy. OP, Operation; POD, postoperative day; VATS, video-assisted thoracoscopic surgery.

Effect of resected lobe on fluid output

The volume of pleural fluid drained varied with the anatomical location of the resected lobe. On the day of surgery, patients who underwent right lower lobectomy exhibited the highest mean fluid output (607.0±330.0 mL), compared to other lobes. However, this initial difference did not reach statistical significance.

Over the complete postoperative period, no significant variation in cumulative drainage volume was observed between the different lobectomy groups. The total fluid output across all days did not differ markedly between patients with upper, middle, or lower lobe resections, suggesting that factors other than resection site—such as surgical technique, individual patient physiology, or perioperative management—may have a greater influence on postoperative pleural fluid production.

Predictive value of early drainage volume

The volume of pleural fluid drained within the first 36 postoperative hours demonstrated a significant prognostic value for the overall duration of drainage. Patients who produced more than 1,000 mL of fluid on the day of surgery experienced a longer mean drainage duration (8.0±4.0 days) compared to those with lesser output (6.0±3.0 days), a difference that was statistically significant (P=0.04).

Similarly, a drainage volume exceeding 500 mL on the first POD was also associated with prolonged drainage (8.0±3.0 vs. 6.0±3.0 days; P=0.003). Notably, patients who exceeded both thresholds, more than 1,000 mL on the operative day and more than 500 mL on the 1st POD, required the longest drainage duration, averaging 9.0±4.0 days, compared to 6.0±3.0 days in others (P=0.01).

These findings suggest that early high-volume drainage is a significant predictor of prolonged chest tube requirement and may assist in identifying patients who could benefit from more targeted postoperative fluid management strategies. While no specific interventions were applied in the present study based on early output volumes—since the predictive association was discovered during retrospective analysis—these results offer a foundation for future prospective management protocols. Potential strategies may include stricter fluid balance control, early renal function monitoring to avoid fluid overload, and serum albumin correction to reduce third-spacing. These tailored approaches could help mitigate prolonged drainage in patients exhibiting early excessive pleural output.

Subgroup analysis: patients with significant air leakage

In the subgroup of patients exhibiting significant postoperative air leakage, defined as a sustained air flow exceeding 100 mL/min, distinct differences emerged between the two drainage systems. Among these patients, the incidence of drain occlusion was notably higher in the conventional drainage group (30%) compared to the coaxial group (5%), reaching statistical significance (P=0.02). While occluded conventional drains were successfully re-opened by manual “milking”, this maneuver proved difficult with coaxial drains due to their internal structural design. Furthermore, in our study, only two patients (one in each group) required reinsertion of a chest tube due to recurrent pleural fluid accumulation after initial chest tube removal. These cases were managed conservatively with successful resolution and without further complications.

Importantly, all patients in both groups were managed using a digital suction system (Thopaz^TM, Medela), which provides regulated negative pressure and real-time flow monitoring. The high rate of occlusion in the conventional drainage group was primarily attributed to the accumulation of coagulated blood or fibrinous debris, especially within the narrow single-lumen design of the silicone Blake drains. These obstructions typically occurred during the early postoperative phase when fluid output was most hematic. Although manual milking effectively restored patency in most cases, the need for this intervention highlights the limitations of conventional drain architecture in managing high-output or clot-prone effusions. Conversely, the coaxial drains—with their central air channel and peripheral fluid grooves—demonstrated improved flow dynamics and resistance to occlusion, potentially offering a structural advantage in patients with persistent air leaks or early serosanguinous output.

Subcutaneous emphysema, a clinically significant complication characterized by the accumulation of air within subcutaneous tissues and frequently associated with discomfort, swelling, and delayed recovery, was notably more prevalent in patients with conventional drains. It occurred in 50% of cases in the conventional group, compared to 40% in the coaxial group. Although this difference did not reach statistical significance, the observed reduction in the coaxial group suggests a clinically meaningful trend. The improved evacuation of air provided by the coaxial system may contribute to minimizing air trapping and subsequent tissue infiltration, thereby lowering the risk of extrathoracic air dissemination and associated morbidity.

Importantly, the duration of drainage in this high-risk subgroup was shorter among patients managed with coaxial drains (6±3 days) compared to those with CTs (7±4 days), indicating superior drainage efficiency in the context of air leaks. These findings support the potential utility of coaxial systems in managing patients with postoperative alveolar-pleural fistulas or other air-leak syndromes, where effective and uninterrupted air evacuation is critical. Moreover, no chemical pleurodesis or reinsertion of chest tube were necessary due to recurrent or residual air leaks in both groups.

Inflammatory response (CRP levels)

CRP levels were assessed on POD 1 through 5 to evaluate systemic inflammatory response. On POD 1, CRP concentrations were comparable between the two groups, with a mean of 85±50 mg/L in the conventional drain group and 72±43 mg/L in the coaxial drain group. However, from POD 3 onward, CRP values were significantly lower in patients with coaxial drains, indicating a reduced postoperative inflammatory response. Specifically, on POD 3, CRP levels averaged 187±60 mg/L in the CT group vs. 133±61 mg/L in the CD group (P<0.01); on POD 4, levels were 145±62 mg/L in the CT group compared to 118±56 mg/L in the CD group (P<0.01); and on POD 5, CRP values were 125±98 vs. 103±68 mg/L, respectively (P<0.01, Figure 4).

Figure 4 Postoperative CRP levels from POD 1 to POD 5 in patients with CT and CD chest drains. From POD 3 onward, CRP levels were significantly lower in the CD group, indicating a reduced systemic inflammatory response associated with CD drainage (P<0.01). CD, coaxial drain; CRP, C-reactive protein; CT, conventional tube; POD, postoperative day.

These findings suggest that the coaxial drainage system is associated with a milder postoperative inflammatory profile. This effect is likely due to more effective evacuation of pleural contents and a lower incidence of drain occlusion, which reduces the risk of retained blood and associated inflammation. Notably, no significant differences in clinical infection rates were observed between the groups, reinforcing the interpretation that the CRP elevation in the CT group reflects inflammatory rather than infectious sequelae of suboptimal drainage.

Discussion

This prospective randomized study compared the clinical performance of conventional single-lumen Blake drains with that of novel coaxial chest drainage systems in patients undergoing VATS lobectomy. The findings demonstrate that while both systems perform similarly in routine fluid and air evacuation, the coaxial drains offer significant clinical advantages in patients with high postoperative air leakage and are associated with reduced inflammatory response and lower complication rates.

One of the most noteworthy findings was the significantly shorter drainage duration in the coaxial group (4±2 days) compared to the conventional group (6±3 days), consistent with earlier reports suggesting faster chest tube removal with more efficient drainage designs (7,8). Additionally, the rate of tube occlusion was dramatically lower with coaxial drains (4%) versus conventional drains (30%) a clinically meaningful reduction supported by previous studies highlighting occlusion as a common and underrecognized complication (5,6). The high incidence of subcutaneous emphysema in the conventional group (56%) compared to the coaxial group (38%) further reinforces the superior air-handling properties of the coaxial system.

The design of the coaxial drain—featuring an inner lumen for air evacuation and external grooves for fluid removal—facilitates continuous dual-channel drainage while minimizing the risk of obstruction. This structural innovation appears to play a crucial role in the improved outcomes observed, particularly in patients with persistent postoperative air leakage, a complication known to prolong hospital stay and increase the risk of infection and reintervention (9).

Another key contribution of this study is the use of CRP levels as a surrogate marker for postoperative inflammation. While CRP values were similar on POD 1, patients in the coaxial group exhibited significantly lower levels from POD 3 to POD 5. This suggests that more efficient drainage may reduce retained fluid or blood and mitigate secondary inflammation. The observed inflammatory attenuation may translate into faster recovery and improved patient comfort, aligning with ERAS protocols that emphasize minimizing surgical stress and promoting early discharge (10).

Notably, early drainage volume was shown to be a strong predictor of prolonged chest tube requirement. Patients draining more than 1,000 mL on the operative day or more than 500 mL on POD 1 required longer drainage durations. These thresholds provide a valuable clinical tool for early identification of patients at risk for delayed recovery, allowing for closer monitoring or tailored postoperative care strategies.

This study also integrates broader clinical perspectives on chest drainage. The emergence of the concept of “drainology” reflects an increasing awareness that optimal drain selection, placement, and management are critical to recovery, particularly in thoracic and cardiac surgery (10). In this context, coaxial drains represent a promising advancement. Their structural and functional advantages address many limitations of traditional drains, including hidden clogging and inefficient air or fluid evacuation, both of which contribute to RBS, local inflammation, and other postoperative complications.

Our findings provide supporting evidence for this association. Patients treated with coaxial drains not only had significantly fewer drain occlusions but also showed a milder postoperative inflammatory response, as reflected by lower CRP levels from POD 3 onward. This trend occurred despite no differences in clinical infection rates between the groups, suggesting that elevated CRP in the conventional group was more likely due to inflammatory sequelae of impaired drainage rather than infection. This aligns with recent literature highlighting the role of retained blood and fibrinous material in triggering localized inflammation and systemic inflammatory markers in the absence of overt infection (11).

Taken together, these results underscore the clinical relevance of advanced drain designs, not only for mechanical efficacy but also for their potential role in minimizing subclinical inflammation, promoting recovery, and reducing length of stay—key targets of ERAS protocols (5,12).

The study reinforces the growing body of evidence advocating for the use of a single, well-designed chest drain after pulmonary resections. Meta-analyses and guideline-based recommendations by the ERAS Society and ESTS support this practice, citing reductions in pain, infection risk, and hospital length of stay (13-15). Importantly, this study adds new prospective data supporting the coaxial design as an ideal single-drain solution due to its dual drainage capacity, flexibility, and lower complication rate.

However, some limitations should be acknowledged. While all patients underwent standardized procedures with digital drainage monitoring, surgeon variability, patient-specific anatomical differences, and comorbidities could still have influenced drainage behavior. Moreover, although CRP provided valuable insight into systemic inflammation, patient-reported outcomes such as pain or mobility were not assessed and warrant future study.

Conclusions

This study provides robust clinical and biochemical evidence supporting the use of coaxial drainage systems after VATS lobectomy. In addition to offering comparable fluid and air evacuation under normal conditions, coaxial drains demonstrate clear advantages in high-risk patients—namely, reduced tube occlusion, lower rates of subcutaneous emphysema, decreased inflammatory response, and shorter drainage duration. These findings support the routine incorporation of coaxial systems into ERAS-aligned thoracic surgery protocols and highlight the importance of early fluid metrics in guiding postoperative care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1169/rc

Trial Protocol: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1169/tp

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1169/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1169/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1169/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Vienna (No. EK20-081-6020) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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