Advantages of negative-pressure suction device compared to traditional chest closed drainage in the management of patients after mediastinal mass resection

Introduction

Mediastinal masses are heterogeneous lesions that arise within the mediastinum (1), first described by Hippocrates in the 5th century BC, yet the mediastinum remained surgically inaccessible until Nassiloff performed the first successful mass resection in 1888 (2). Subsequently, advances in anaesthetic techniques, radiological imaging, and surgical approaches—particularly the development of minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS) in 1993 and robotic surgery in 2003—have dramatically improved the diagnosis, treatment, and outcomes of patients with mediastinal masses (2). With the increasing use of chest computed tomography (CT) screening, their detection rate has risen, and they are often found incidentally, occurring in approximately 0.5–2.0% of the screened population (3,4). The advancement of imaging technologies, including multimodal methods such as ¹⁸F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT), has enhanced the diagnostic capability for various thoracic diseases (5), thereby facilitating more accurate preoperative assessment of mediastinal lesions. Surgical resection is the gold standard for definitive diagnosis, and remains the most effective approach for complete lesion removal, preventing malignant transformation, and relieving compressive symptoms (6,7). With the development of minimally invasive techniques such as thoracoscopic surgery, resection has become safer, less traumatic, and conducive to faster recovery (8). Optimizing perioperative management to enhance recovery and prevent complications is therefore crucial. Thoracic drainage, a standard component of postoperative management, facilitates the removal of residual fluid and air, thereby reducing complication risk (9).

There are various methods for managing thoracic drainage after thoracic surgery (9,10). Negative-pressure suction device (NPSD) maintains pleural cavity pressure below atmospheric levels, facilitating timely evacuation of air and fluid to prevent effusion, pneumothorax, and other complications (11). In contrast, closed thoracic drainage uses a one-way valve or water seal to prevent backflow while allowing continuous drainage (12). With the broader implementation of enhanced recovery after surgery (ERAS) protocols, optimizing drainage systems to reduce discomfort and enhance recovery has become a major clinical priority (13,14). Studies show that new-generation flexible devices, such as multi-channel silicone negative-pressure drains, reduce trauma, lessen pain, and promote early mobilization, while performing as well as or better than traditional rigid tubes in terms of complication rates, chest tube duration, and length of stay (15). Randomized trials further demonstrate that low-intensity negative pressure reduces postoperative pain and analgesic use and shortens hospital stay without increasing pneumothorax or effusion risk (15,16). Overall, current evidence-based research indicates that NPSDs have good application advantages in accelerating recovery.

This study used a retrospective cohort study design to evaluate the impact of connecting or not connecting the chest tube to NPSD after mediastinal mass resection on hospitalization outcomes. Existing research has mainly focused on areas like lung resection and esophagectomy, while studies specific to mediastinal mass resection are relatively lacking. The uniqueness of this study lies in its focus on the specific disease population of mediastinal masses. This study will provide important references for the implementation of ERAS in the postoperative management of mediastinal mass. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2512/rc).

Methods

Study population

This study is a retrospective study that included 174 inpatients who were diagnosed with mediastinal masses by chest CT and all underwent thoracoscopic mediastinal mass resection in a single Chinese center between September 2021 and February 2025. Inclusion criteria were: (I) age 18–80 years; (II) patients with mediastinal masses confirmed by imaging examination; (III) patients who underwent mediastinal mass resection and placement of a chest drainage tube; (IV) patients with complete clinical data, including postoperative chest tube management and recorded hospitalization outcomes. Exclusion criteria included: (I) patients undergoing simultaneous lobectomy, segmentectomy, or other major thoracic surgery; (II) patients converted to open-chest surgery intraoperatively; (III) history of severe thoracic adhesions or previous thoracic surgery; (IV) patients with severe coagulation disorders, active thoracic infection, or serious heart, lung, or brain diseases preoperatively; (V) patients with incomplete data. The diagnosis of all patients was confirmed by preoperative imaging and postoperative pathology. For patients with pathological results confirming malignant thymic tumors, typing and staging were conducted according to the 2025 National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology-Thymomas and Thymic Carcinomas (17). The study was approved by the Ethics Committee of Tianjin Medical University General Hospital (approval No. IRB2025-YX-454-01). Due to the retrospective nature of the study, the Ethics Committee waived the requirement for informed consent. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Surgery and drainage tube placement

Under general anesthesia with single-lumen endotracheal intubation, the patient was placed in a head-up supine position. Endoscopic ports were established below the xiphoid process and along the bilateral midclavicular lines at the same level. The bilateral thymic lobes were dissected from the lower to upper poles, and the mediastinal mass and thymus were resected en bloc. A thoracic drainage tube was placed through the right port afterward. All patients underwent surgery performed by experienced thoracic surgeons according to NCCN Clinical Practice Guidelines. In this retrospective study, patients were allocated to two groups based on the postoperative drainage device used: the traditional chest closed drainage (TCCD) group and the NPSD group. The drainage device selection was made by the attending surgeon considering surgical circumstances, equipment availability, and individual patient factors. In the TCCD group, a 24 Fr chest tube was inserted at the intersection of the 7th intercostal space and the midclavicular line, with the distal end positioned at the pleural apex and connected to a water-seal drainage system. In the NPSD group, a 19 Fr catheter was placed at the same anatomical location and connected to a portable balloon device (Figure 1). Negative pressure was generated manually by compressing the balloon, nursing staff monitored the balloon every 2–4 hours, re-compressing it when expansion exceeded 50% to maintain adequate negative pressure. This portable, lightweight device permitted unrestricted patient mobility, though negative pressure maintenance depended on regular nursing intervention. Since the NPSD device was introduced and progressively adopted during the study period while TCCD remained in continuous use throughout, temporal differences between groups may introduce bias, which we address in the “Discussion” section.

Figure 1 NPDS group negative pressure drainage ball schematic diagram. NPSD, negative-pressure suction device.

Postoperative management

All patients underwent blood routine tests, coagulation function tests, liver and kidney function tests, and electrolyte tests on the first postoperative day, with re-examination every 3 days thereafter. Postoperative pain intensity was assessed using the Numerical Rating Scale (NRS), an 11-point scale where patients rated their pain from 0 (no pain) to 10 (worst imaginable pain). Pain scores were categorized as mild [0–3], moderate [4–6], or severe [7–10] based on established clinical thresholds. Two nurses independently recorded NRS scores at 24 hours postoperatively, and the average value was used for grading and statistical analysis to minimize measurement bias. Routine chest X-ray examination was performed on the first postoperative day to assess chest tube position and overall thoracic cavity status. The nursing team routinely monitored the patients’ axillary temperature and drainage volume every day. For pain control, all patients received intravenous injection of flurbiprofen axetil injection (50 mg, twice daily) according to the institution’s standard procedure, and no paravertebral block was performed. Postoperatively, under the primary physician’s assessment, the drainage tube was removed once all the following criteria were met: 24-hour drainage volume less than 150–200 mL; drainage was serous rather than bloody or chylous; no air leak or air leak had stopped for at least 24 hours; chest X-ray showed sharp costophrenic angles, with no obvious effusion or pneumothorax; the patient did not have dyspnea, vital signs were stable, and there was no evidence of infection (18). The criteria for patient discharge are as follows: normal vital signs; successful removal of the chest tube with no complications requiring hospitalization (19).

Outcomes

The primary outcome indicators of this study are clinical metrics related to hospitalization, including chest tube duration and length of stay. Postoperative drainage duration is defined as the number of days from the end of surgery until the chest drainage tube is completely removed; length of hospital stay refers to the total number of days from the day of surgery to the day of discharge; secondary indicators include the reinsertion rate of chest tube and the incidence of postoperative fever. The rate of tube reinsertion refers to the proportion of patients who require re-insertion of a drainage tube after the chest drainage tube has been removed postoperatively; postoperative fever is defined as a postoperative body temperature ≥38.0 ℃ persisting for ≥24 hours; complications such as pulmonary infection, pneumothorax, and mediastinal emphysema are independently determined by two experienced clinicians and confirmed by the attending physician. All outcome data are collected through the electronic medical record system and documented in a structured table, entered by two independent researchers and cross-checked by a third researcher to ensure accuracy. This study follows the STROBE guidelines, thoroughly disclosing potential sources of bias and their possible impact on the interpretation of results, thus enhancing the transparency and reliability of the research.

Statistical analysis

All data were statistically analyzed using SPSS 27.0 software (IBM, Armonk, NY, USA). Normality tests for continuous variables were conducted with histograms and the Kolmogorov-Smirnov test. Normally distributed continuous variables are expressed as mean ± standard deviation (SD), and comparisons between groups were performed using the independent samples t-test. Non-normally distributed continuous variables between two groups are expressed as median [interquartile range (IQR)], and comparisons were performed using the Mann-Whitney U test. For multiple graded or staged data, the Kruskal-Wallis H test was used. Categorical variables are expressed as counts and percentages, and comparisons between groups were made using Pearson’s Chi-squared test or Fisher’s exact test. Time-to-event data were analysed using Kaplan-Meier survival curves to compare the cumulative probability of chest tube removal and hospital discharge between groups. The log-rank (Mantel-Cox) test was used to assess statistical significance of differences in time distributions. To evaluate the independent effect of drainage device type, a generalized linear model with log link function and gamma distribution was employed, adjusting for potential confounders including sex, age, body mass index (BMI), smoking status, comorbidities (diabetes mellitus, hypertension, coronary heart disease, myasthenia gravis, chronic obstructive pulmonary disease/emphysema), American Society of Anesthesiologists (ASA) physical status classification, and pathological type. Results are reported as ratios of means (RoM) with 95% confidence intervals (CIs). A sensitivity analysis was conducted excluding patients with myasthenia gravis (n=38) to assess the robustness of the primary findings. All statistical tests were two-sided, and a P value <0.05 was considered statistically significant. All statistical analyses were independently performed by two researchers, with a third person reviewing to ensure accuracy.

Results

A total of 174 patients who underwent mediastinal mass resection were included. Among them, 111 patients received conventional water-seal drainage, and 63 patients received a NPSD. Baseline characteristics were generally comparable between groups in terms of gender, age, smoking status, pathological type or most chronic comorbidities (all P>0.05). ASA physical status was also similar (P=0.75), and most patients were classified as ASA II (81.1% vs. 84.1%). However, BMI was significantly higher in the NPSD group (26.29±4.49 vs. 24.89±3.84 kg/m², P=0.03). A significant difference was also observed in myasthenia gravis prevalence, which was lower in the NPSD group (9.5% vs. 28.8%, P=0.003) (Table 1).

In terms of perioperative outcomes, the NPSD group had significantly shorter chest tube duration (57.43±18.99 vs. 66.54±20.40 h; median 60.85 vs. 65.43 h, P=0.002) and length of stay (3.52±1.02 vs. 4.02±1.21 d; median 3.61 vs. 3.81 d, P=0.002) compared to the TCCD group. There were no significant differences in postoperative pain scores (P=0.13), white blood cell count (P=0.26), postoperative fever (P=0.33), or total drainage volume (P=0.54). None of the patients underwent chest tube reinsertion after surgery (Table 2).

Kaplan-Meier survival analysis showed that compared with the TCCD group, the NPSD group had significantly shorter time to chest tube removal (median 60.85 vs. 65.43 hours, log-rank P=0.009) and length of hospital stay (median 3.61 vs. 3.81 days, log-rank P=0.003) (Figures 2,3). The survival curves demonstrated sustained separation throughout the observation period, with the NPSD group consistently showing lower cumulative probability of retaining chest tubes and remaining hospitalized, supporting the shorter time-to-event outcomes shown in Table 2.

Figure 2 Kaplan-Meier curves for time to chest tube removal. NPSD, negative-pressure suction device; TCCD, traditional chest closed drainage.

Figure 3 Kaplan-Meier curves for time to hospital discharge. NPSD, negative-pressure suction device; TCCD, traditional chest closed drainage.

Among the 78 patients with malignant thymic tumors, 50 were in the TCCD group and 28 in the NPSD group. Stage I disease was more frequent in the NPSD group (32.1% vs. 18.0%), whereas stage II predominated in the TCCD group (74.0% vs. 64.3%). Stage III occurred only in the TCCD group (6.0% vs. 0.0%), and stage IV was comparable between the two groups (2.0% vs. 3.6%). The overall distribution of Masaoka stages showed no significant difference between the groups (P=0.13), indicating that there was no substantial selection bias between the two drainage methods with respect to tumor stage (Table 3).

In multivariable analysis adjusting for sex, age, BMI, smoking status, comorbidities (diabetes mellitus, hypertension, coronary heart disease, myasthenia gravis, chronic obstructive pulmonary disease/emphysema), ASA physical status classification, and pathological type, TCCD use remained significantly associated with prolonged chest tube duration (RoM 1.17, 95% CI: 1.07–1.27, P<0.001) and prolonged length of stay (RoM 1.15, 95% CI: 1.07–1.24, P<0.001) compared with NPSD (Table S1). Among potential confounders, myasthenia gravis independently predicted longer hospital stay (RoM 1.14, 95% CI: 1.04–1.26, P=0.006), and both age and BMI were associated with prolonged recovery time (both P<0.01).

Sensitivity analysis excluding all patients with myasthenia gravis (n=38, remaining n=136) demonstrated even more pronounced treatment effects. TCCD use was associated with a 21% increase in chest tube duration (RoM 1.21, 95% CI: 1.10–1.33, P<0.001) and a 19% increase in length of stay (RoM 1.19, 95% CI: 1.10–1.28, P<0.001) compared with NPSD (Table S2). These findings confirm the robustness of NPSD superiority over TCCD, independent of baseline characteristic imbalances between groups.

Discussion

This study investigated whether NPSDs affect in-hospital outcomes following mediastinal mass resection. Strict inclusion and exclusion criteria ensured cohort homogeneity and minimized selection bias in this consecutively enrolled real-world cohort. Despite comparable baseline characteristics, adjusted analysis confirmed that traditional water-seal drainage remained significantly associated with prolonged chest tube duration and length of stay. Sensitivity analysis strengthened these findings, demonstrating that the superiority of NPSD exists independently of myasthenia gravis distribution. Age and BMI emerged as independent predictors of prolonged recovery, suggesting their incorporation into perioperative risk stratification and individualized management. Detailed chart review integrated with clinical workflows defined and validated key outcomes, providing evidence-based support for NPSDs to accelerate postoperative recovery and shorten hospital stay without increasing major adverse events in mediastinal mass surgery, with generalizability and clinical applicability.

Similar findings were reported by Cui et al. (16), who demonstrated that under ERAS protocols, patients undergoing VATS lobectomy with low negative-pressure bulb drainage had lower postoperative pain scores, reduced analgesic use, shorter drainage duration and hospital stay compared with those using traditional water-seal drainage (drainage time 3.89±1.63 vs. 5.10±2.02 days, hospital stay 5.40±1.65 vs. 6.37±1.99 days, all P<0.05), with no significant difference in complications. Similarly, Law et al. (20) reported that vacuum negative-pressure drainage after esophagectomy was safe, with 94% of patients completing drainage without switching to water-seal systems. Consistently, Wang et al. (15) reported that a multi-channel silicone NPSD effectively reduced postoperative pain scores and analgesic use while promoting early ambulation. Their study focused on patients undergoing single-port thoracoscopic surgery for lung cancer, representing a more homogeneous cohort, whereas the present study mainly included mediastinal mass resections, thereby enhancing the generalizability of the conclusions. Differences in outcomes, such as hospital stay or drainage duration, might be attributed to variations in tube-removal criteria or perioperative protocols. Likewise, this study found no significant difference in postoperative pain, which may relate to the use of a 28 Fr rigid chest tube in Wang’s control group, larger than those applied in the conventional closed drainage group here. Overall, evidence across studies supports that negative‑pressure drainage promotes recovery and can be safely applied to various thoracic surgical procedures, including mediastinal mass resection.

The use of NPSD shortened drainage time by 9.11 hours and hospital stay by 0.5 days. Multivariate analysis showed that after adjusting for confounding factors, the TCCD group had 17% longer drainage time and 15% longer length of stay than the NPSD group. Although the absolute reduction is modest, from the patient perspective, shorter drainage time means earlier tube removal and faster recovery of mobility. This aligns with the core concept of ERAS: Batchelor emphasized optimizing postoperative recovery through synergistic effects of multiple small improvements (13). Within ERAS pathways, early mobilization, proactive chest tube management, and opioid-sparing analgesia are key elements of postoperative care (13,21,22). Longitudinal studies by Thompson et al. and Lee et al. confirmed that shortening drainage tube duration directly facilitates early patient mobilization, thereby preventing functional decline, muscle atrophy, and harmful effects of bed rest (23,24).

From a broader perspective of ERAS implementation, even modest reductions in length of stay hold significant clinical value. Sauro et al.’s meta-analysis of 84 randomized controlled trials showed that ERAS protocols reduced length of stay by a mean of 1.88 days and decreased postoperative complications to a relative risk of 0.60 (25). In thoracic surgery, Khoury et al.’s meta-analysis including 19 studies and 8,447 patients showed ERAS reduced length of stay by an average of 3 days (26). Goldblatt et al.’s systematic review confirmed that shortened length of stay is not accompanied by increased readmission rates (27). Therefore, the 0.5-day reduction in length of stay observed in this study may reduce nosocomial complication risks and alleviate healthcare resource burden within the ERAS framework. Early tube removal and discharge align with patients’ expectations for rapid recovery, enhance patient satisfaction, and may facilitate timely adjuvant therapy (27,28).

Physiologically, negative-pressure drainage maintains a stable pleural pressure gradient, promoting efficient evacuation of fluid and residual air and facilitating lung re-expansion (29). The application of multi-slot flexible silicone tubes combined with digital management systems optimizes drainage smoothness, improves patient mobility and comfort, and supports early ambulation and faster recovery (15,30). The NPSD used in this study is also suitable for postoperative cardiac patients (31). Based on current evidence and clinical practice, the rational application of NPSDs should be promoted in cardiothoracic surgeries, with prompt drainage-tube removal once removal criteria are achieved to reduce discomfort and facilitate early mobilization and recovery. However, the timing of tube removal must be individualized, particularly for elderly or frail patients with multiple comorbidities (32). Future research should focus on developing more personalized criteria for tube removal, including the use of digital precision‑drainage systems and approachspecific management pathways (33,34).

Nonetheless, several limitations warrant consideration. The retrospective single-center design limits external generalizability, and multicenter validation is needed. The cohort primarily comprised adult patients with mediastinal masses without severe comorbidities, excluding those with complex thoracic anatomy, prior thoracic surgery, or severe underlying diseases, and was predominantly Chinese; thus, caution is advised when extrapolating to other populations or ethnicities. Patients were grouped by drainage device used postoperatively rather than randomly assigned, introducing potential selection bias. Since the NPSD was gradually implemented during the study period, temporal confounding may exist from surgical team maturation and evolving perioperative protocols. Additionally, tube diameter differed between groups (NPSD: 19 Fr; TCCD: 24 Fr), determined by device design. Smaller catheters may reduce tissue trauma and pain, potentially explaining why NPSD patients experienced milder pain and shorter indwelling times. However, smaller diameters may also affect drainage efficiency, particularly for viscous fluids or clots. Therefore, the observed advantages in the NPSD group may result from combined effects of negative pressure mechanism and smaller tube caliber, making it difficult to distinguish their independent contributions. As an observational study, it can identify associations but cannot establish causality, and unmeasured confounders may persist. Additionally, follow-up focused on in-hospital and short-term outcomes without assessing long-term quality of life. Future multicenter studies with extended follow-up are needed to validate and refine these findings.

Conclusions

In summary, despite methodological heterogeneity across studies, most evidence supports that NPSD facilitates postoperative recovery and reduces patient discomfort. Future large-scale prospective randomized controlled trials are needed to identify optimal drainage strategies across different surgical types and patient populations.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2512/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2512/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2512/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2512/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 Tianjin Medical University General Hospital (approval No. IRB2025-YX-454-01). The requirement for informed consent was waived due to the retrospective nature of the study.

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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