Tubeless strategy following thoracoscopic pulmonary wedge resection: a safe and beneficial option in selected patients

Introduction

The adoption of video-assisted thoracoscopic surgery (VATS) has become the standard approach for the surgical resection of early-stage lung cancer (1). Uniportal VATS, especially, has been widely applied as a minimally invasive procedure. Several previous studies have shown that uniportal VATS is more effective in relieving postoperative pain than triple-port VATS (2,3). Postoperative placement of a thoracic drainage tube is considered necessary, and the primary use is for postoperative monitoring. However, the drainage tube itself is a significant source of patient discomfort, contributing to increased incision pain, impeded early ambulation, prolonged hospital stays, and decreased overall satisfaction (4-6).

Previous studies have suggested that series drainage strategies with catheters in particular patients undergoing uniportal VATS lung surgery showed advantages in alleviating postoperative pain with adequate safety and efficacy. In addition, we demonstrated that catheter drainage is a safe alternative to chest tubes following wedge resection and reduces postoperative pain (7,8). Building upon this foundation, the logical next step is to investigate the feasibility and potential benefits of eliminating postoperative drainage altogether.

This direction of inquiry is underscored by a recently published protocol for a randomized controlled trial specifically designed to evaluate the safety of avoiding chest drains after VATS wedge resection (9). Therefore, we conducted this study to directly compare a complete tubeless strategy (no drainage tube or catheter) against catheter drainage in a well-defined patient cohort. We hypothesized that for carefully selected patients undergoing VATS wedge resection, the tubeless strategy would yield superior outcomes, specifically by further reducing operative time and postoperative pain, without increasing the incidence of perioperative complications. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2354/rc).

Methods

Study design, setting, and participants

This single-center, retrospective cohort study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Guangdong Provincial People’s Hospital (approval No. XJS2021-019-01; approval date: July 6^th, 2021). Informed consent was waived in this retrospective study. Patients who underwent pulmonary wedge resection under VATS in Guangdong Provincial People’s Hospital between September 2020 and November 2024 were enrolled (Figure 1). This period defined the recruitment and data collection timeframe. All patient data were retrospectively extracted from the electronic medical records system for analysis.

Figure 1 Flow diagram of data process for patients after lung wedge resection. PSM, propensity score matching.

Participant selection and matching criteria

The study consecutively enrolled patients who underwent VATS pulmonary wedge resection at our hospital between September 2020 and November 2024. Participant selection was based on the following criteria: (I) inclusion criteria: age ≥18 years, solitary pulmonary nodule amenable to wedge resection, and intraoperative assessment of low risk for complications; (II) exclusion criteria: conversion to thoracotomy, dense pleural adhesions, intraoperative air leakage lasting >5 minutes after lung recruitment, or requirement for additional major procedures. Data were extracted from our prospectively maintained electronic medical record system.

To minimize confounding bias, we performed 1:1 propensity score matching (PSM) between the catheter and tubeless groups. The matching covariates included gender, age, body mass index (BMI), smoking history, nodule size, nodule number, nodule location, and pathology, with a caliper width set to 0.25. After matching, 133 pairs of patients (133 in the catheter group and 133 in the tubeless group) were generated, achieving well-balanced baseline characteristics between the groups (Figure 2). The effectiveness of matching was confirmed by the balanced distribution of all included covariates, as detailed in Table 1.

Figure 2 The absolute standardized mean difference after model matching. BMI, body mass index; Nums, numbers.

Variable definitions

The primary exposure in this study was the postoperative thoracic drainage strategy, with patients assigned to either a tubeless group (no drainage tube or catheter) or a catheter drainage group. Data for all study variables were sourced from our hospital’s prospectively maintained electronic medical record system. The primary outcomes were operative duration, defined as the time from skin incision to closure in minutes, and postoperative pain intensity, which was assessed using the Numerical Rating Scale (NRS, range 0–10) within the first 24 hours after surgery. Secondary outcomes included the incidence of postoperative complications (such as pneumothorax or subcutaneous emphysema, confirmed by clinical examination and chest radiography), the rate of subsequent chest tube placement (reintubation), and the length of postoperative hospital stay in days. Potential confounders identified for adjustment through PSM included gender, age, BMI, smoking history, nodule size, nodule number, and nodule location. The assessment of specific effect modifiers was not a predefined aim of this analysis.

Intraoperative assessment and criteria for tubeless strategy selection

The decision to proceed with the tubeless strategy was made intraoperatively by the attending surgeon based on a structured assessment of surgical complexity and risk. Clear, predefined eligibility criteria were applied: (I) absence of significant pleural adhesions: the pleural cavity was assessed as having only filmy, avascular adhesions (equivalent to Grade 0–1) that could be divided bluntly or with minimal electrocautery without causing significant parenchymal injury or bleeding; (II) adequate hemostasis: the resection margin and surgical field were confirmed to be completely dry with no active bleeding after standard maneuvers (electrocautery, compression) and a period of observation; (III) no persistent air leak: the presence of air leak was assessed intraoperatively using the catheter aspiration method described in “Operative management” section. After lung recruitment and prior to final muscular closure, a 16-French (Fr) red rubber catheter was inserted. If continuous air leakage was observed during the manual aspiration procedure (i.e., air could be aspirated repeatedly without cessation), the case was deemed ineligible for the tubeless strategy, and a chest tube was placed; (IV) favorable nodule characteristics: the nodule was peripherally located within the outer one-third of the lung parenchyma as estimated visually or confirmed by intraoperative palpation/imaging, and amenable to a straightforward wedge resection. Patients with severe emphysematous changes (e.g., bullous disease) or diffuse parenchymal fragility that, in the surgeon’s judgment, posed an undue risk for postoperative air leak, were excluded. Patients meeting all the above criteria were considered eligible for the tubeless strategy. The presence of any one of the following led to the placement of a drainage catheter: dense vascular adhesions, persistent air leak, unsatisfactory hemostasis, or central/deep lesion location requiring more extensive dissection. These intraoperative factors, while pivotal for clinical decision-making, were not included as variables in the PSM model due to their qualitative and surgeon-assessed nature in the retrospective record.

Intraoperative intervention

The appropriate intercostal space was selected as the sole operating port based on the location of the nodule, with an incision length not exceeding 4 cm. Before entering the pleural cavity, care was taken to avoid accidental injury to the visceral pleura with the electrocautery to preserve pleural integrity. The anatomical position of the nodule was identified according to preoperative planning or localization markers, and the lesion was resected using a linear stapler.

Operative management

During the procedure, excessive traction or lifting of the lung tissue was avoided to prevent iatrogenic injury. The resection margin was carefully inspected for bleeding, and hemostasis was meticulously achieved. The anesthesiologist was then asked to perform suctioning and lung inflation. When the lung approximated the muscular layer of the incision, closure of the muscle layer was initiated. Prior to complete muscular closure, a 16-Fr red rubber catheter was inserted through the residual incision gap. The external end of the catheter was connected to negative pressure for 30 seconds. A 50 mL syringe was then used to manually aspirate any residual air from the pleural space while gradually withdrawing the catheter until it was fully removed, and no further air could be aspirated (Figure 3). It is important to note that if continuous air leakage was observed during aspiration, the tubeless strategy was abandoned, and a catheter tube was placed instead.

Figure 3 Operation demonstration diagram of the tubeless strategy.

After surgery, the anesthesiologist was instructed to ventilate both lungs with low tidal volume, and the patient was transferred to the recovery room. In cases of significant subcutaneous emphysema or tension pneumothorax accompanied by decreased oxygen saturation, a catheter tube was reinserted.

Postoperative drainage protocol for the catheter group

Postoperative management for the catheter drainage group followed the standardized protocol established in our previous randomized trial (7). Device and placement: a 7-Fr double-lumen central venous catheter (20 cm in length) was percutaneously inserted into the second intercostal space upon completion of the wedge resection, serving as the drainage conduit. Management and monitoring: the catheter was not connected to a continuous underwater-seal drainage system. Instead, a standardized, intermittent air-extraction protocol was followed. Nurses or surgeons used a 50 mL syringe to aspirate pleural air via the catheter at predetermined intervals (e.g., every 8 hours) and as clinically indicated. Clinical monitoring included regular assessment of respiratory status, oxygen saturation, and signs of subcutaneous emphysema. A chest radiograph was obtained on the first postoperative morning for all patients. Removal criteria: the drainage catheter was removed when the following criteria were met, consistent with prior work (7): (I) clinical stability with oxygen saturation ≥95% on room air; (II) chest radiograph confirming adequate lung expansion without significant pneumothorax; and (III) minimal or no air could be aspirated through the catheter upon attempted extraction, indicating resolution of active air leak.

Postoperative monitoring and complication assessment

All patients underwent systematic clinical and radiographic monitoring after surgery. Imaging schedule: a mandatory upright chest radiograph was obtained for all patients on the first postoperative morning. Definition and grading of complications: pneumothorax was detected on chest radiograph and categorized as minimal (apical or involving <20% of the hemithorax), moderate (20–50%), or large (>50% or causing mediastinal shift). Subcutaneous emphysema was assessed clinically by palpation and graded as mild (localized to the incision site), moderate (extending to the chest wall or neck), or severe (involving the face, abdomen, or limbs, or causing patient discomfort or respiratory compromise). These classifications guided clinical management decisions, such as the need for supplemental oxygen, enhanced pulmonary toilet, or intervention (e.g., needle aspiration or chest tube placement). To standardize postoperative pain management, all patients received a uniform analgesic regimen: intravenous parecoxib sodium (40 mg twice daily) on the first postoperative day, followed by oral celecoxib (200 mg twice daily) until discharge. No routine regional analgesic blocks were administered.

Statistical analysis

Data management and statistical analysis were performed using SAS 9.4 (version 9.4). Categorical variables were subjected to analysis using the Chi-squared test or Fisher’s exact test, while continuous variables were compared using t-test. For quantitative data that did not follow normal distribution, median interquartile range was used to describe, and Wilcoxon signed-rank test was used for comparison between groups. Significance was accepted as a P value less than 0.05 for all analyses.To control for potential confounding, we performed 1:1 PSM using gender, age, BMI, smoking history, nodule size, nodule number, nodule location, and pathology as matching covariates, with a caliper width set to 0.25. Subgroup analyses and interaction tests were not performed as they were not pre-specified in the study design. Missing data were minimal in this cohort due to the standardized electronic medical record system; any records with essential missing variables were excluded from the analysis. As a retrospective cohort study with complete inpatient data, no loss to follow-up occurred during the postoperative hospitalization period. No sensitivity analyses were conducted given the consistent and complete nature of the data source. Due to the retrospective nature of this study and the aggregated format of the available data, a formal statistical comparison of temporal trends (e.g., year-by-year distribution) between the matched groups was not feasible. The potential influence of the learning curve and evolving practice patterns over time is addressed as a key consideration in the “Discussion” section.

Results

Participant flow and baseline characteristics

A total of 460 patients who underwent VATS pulmonary wedge resection between September 2020 and November 2024 were initially assessed for eligibility and all were included in the study, as detailed in the flow diagram (Figure 1). No missing data were observed for any variables included in the analysis. Table 2 describes the baseline characteristics of the enrolled population. Briefly, of the 460 enrolled patients, 154 (33.5%) were male and 306 (66.5%) were female, with a mean age of 50.21 years. The vast majority (424 patients, 92.2%) underwent a single wedge resection, while 34 (7.4%) and 2 (0.4%) patients had two and three nodules resected, respectively.

Prior to matching, the cohort consisted of 327 patients in the catheter group and 133 in the tubeless group. PSM was then applied to balance baseline characteristics, resulting in 133 well-matched pairs (266 patients in total) for the final comparative analysis. The baseline characteristics both before and after matching are comprehensively detailed in Table 1, which demonstrates that all measured covariates were well-balanced after matching. This balance was further confirmed by the absolute standardized mean differences shown in Figure 2.

Outcome data and main results

Comparison of postoperative outcomes between the matched groups is summarized in Table 3. The median follow-up time was equivalent to the postoperative hospital stay for all patients. The tubeless group (surgical technique illustrated in Figure 3) demonstrated a significantly shorter operative duration (57.00 vs. 80.00 min, P<0.001) and lower postoperative pain scores (NRS: 0.00 vs. 2.00, P<0.001). The incidence of postoperative subcutaneous emphysema was significantly higher in the catheter group than in the tubeless group (60.90% vs. 24.06%, P<0.001), while intraoperative adhesions were more frequently observed in this group (15.04% vs. 6.02%, P=0.02).

No significant differences were observed in other postoperative complications, reintubation rates, intraoperative blood loss, or length of hospital stay. No subgroup or sensitivity analyses were conducted beyond the primary matched analysis.

Discussion

Chest drains have been conventionally employed in thoracic surgery to evacuate air and fluid from the pleural space. However, their use is frequently associated with increased postoperative pain, impaired ventilation, and delayed ambulation (10,11). This study demonstrates that a tubeless strategy following VATS wedge resection is clinically feasible and associated with several significant benefits in carefully selected patients. This conclusion is strongly supported by a recent prospective study focusing specifically on total tubeless single-port thoracoscopic wedge resection, which also reported high feasibility and favorable patient outcomes with a comparable approach (12). Consistent with our pre-specified hypothesis, the tubeless approach resulted in a substantially shorter operative duration and markedly reduced postoperative pain scores compared to catheter drainage, without increasing the risk of major complications, reintubation rates, or prolonging hospital stay. These findings directly address our primary research objective and support the selective omission of thoracic drainage in low-risk patients.

The marked disparity in the size of the original cohorts (133 vs. 327 patients) underscores that the tubeless strategy was applied under highly selective institutional criteria. This non-randomized assignment represents the fundamental context for interpreting our results. Despite PSM on available variables, unmeasured factors related to surgical complexity—such as lung parenchyma quality (e.g., emphysema) or deep lesion location—likely influenced both patient selection and outcomes. Therefore, the reduction in operative time should be interpreted as an indicator of persistent selection bias rather than a direct benefit of the technique.

Notwithstanding these limitations, our findings contribute to the growing evidence that selective omission of thoracic drainage is feasible and beneficial (13,14). Our study extends this literature by providing a direct, propensity-matched comparison between catheter drainage and a complete tubeless strategy, addressing the practical question of whether omitting drainage altogether a safe and advantageous next step for selected patients is. Success across studies consistently depends on identifying a low-risk cohort, often through similar strict criteria (13,14). This reinforces the principle that the strategy’s safety is inextricably linked to patient selection, not merely technical execution. Therefore, the generalizability of our results is specifically and intentionally confined to a well-defined, low-risk population—namely, patients undergoing wedge resection for peripheral nodules, with no significant emphysema/fibrosis, minimal adhesions, and no persistent air leak upon intraoperative testing. By detailing these explicit criteria and demonstrating comparable safety to catheter drainage, our work moves beyond reporting feasibility to offer a reproducible clinical framework. This approach aligns with the evolving paradigm of risk-stratified and tactical chest drain management, which emphasizes selective drain minimization or omission for low-risk patients (15). This framework aids surgeons in answering the critical “how to select” question, aiming to translate the benefit of reduced postoperative pain into consistent clinical practice while maintaining safety.

An interesting finding was the significantly higher incidence of subcutaneous emphysema in the catheter group. This is likely a technical phenomenon attributable to the catheter itself potentially creating a track for air dissection. Importantly, most of these episodes were mild to moderate, caused minimal discomfort, and resolved spontaneously without intervention. Thus, this difference did not translate to a clinically meaningful increase in patient recovery.

Regarding post-discharge safety: a focused review confirmed no unplanned 30-day readmissions or emergency visits for drain-related complications in the tubeless cohort. However, systematic 30-day follow-up data for the entire cohort were not part of this retrospective design, precluding a comparative analysis and highlighting a need for prospective data collection.

Our study has several important limitations that must be considered when interpreting the findings, many of which could bias the results in favor of the tubeless group. First, its retrospective, single-center design may limit the external validity of our findings and introduces the potential for unmeasured confounding despite our matching efforts. Second, an unmeasured “learning curve” effect is probable, as increasing surgical proficiency over the study period coincided with the adoption of the tubeless strategy, potentially confounding the observed improvements in operative efficiency. Third, despite predefined criteria, the final intraoperative selection for the tubeless strategy remained a surgeon-dependent assessment. Nuanced factors critical to this decision were not quantified in our dataset, leaving the analysis vulnerable to residual confounding. Fourth, while our sample size was adequate for detecting differences in primary outcomes, it may be underpowered to identify rare but serious complications, warranting caution. Fifth and critically, our safety assessment is confined to the in-hospital period; the lack of systematic post-discharge data (e.g., on 30-day readmissions) means we cannot fully capture the post-discharge complication profile. Finally, the absence of long-term follow-up precludes any assessment of chronic pain or very late sequelae.

To overcome these limitations and provide a more definitive comparison, future research should strive to prospectively collect and incorporate more granular, objective metrics of surgical complexity—such as quantitative computed tomography (CT) assessment of lung parenchyma quality and precise lesion depth—into comparative analyses. Ultimately, a well-designed randomized controlled trial, stratifying patients based on these refined risk factors, would be invaluable to eliminate residual confounding and establish the true causal effect of a tubeless strategy on patient recovery.

Conclusions

Our pursuit of a tubeless strategy aligns with the ongoing paradigm shift in thoracic surgery towards truly minimalist approaches, which aim to reduce every potential source of invasiveness, from anesthesia to postoperative drainage (16). In conclusion, this study provides a rigorously matched comparison that supports the safety and patient-benefit of advancing from catheter drainage to a complete tubeless strategy in a meticulously selected cohort. The primary clinical contribution is the demonstration that this approach can significantly reduce early postoperative pain without compromising perioperative safety. The operative time difference, likely confounded by case selection, should not be considered a primary benefit. The explicit intraoperative criteria presented here offer a practical framework for other centers to safely implement and further evaluate this strategy.

Acknowledgments

The authors sincerely thank members of the Department of Pulmonary Surgery and all the research participants of Guangdong Lung Cancer Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2354/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2354/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2354/prf

Funding: This work was supported by the Noncommunicable Chronic Diseases-National Science and Technology Major Project (No. 2024ZD0529400), National Natural Science Foundation of China (No. 82573732), National Natural Science Foundation of China Major Joint Project on Key Scientific Issues of Lung Cancer (No. 82241235), National High-Level Talents Special Support Program (No. KA0120231004), and Guangdong Provincial Key Laboratory of Lung Cancer Translational Medicine (No. 2017B030314120).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2354/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 Guangdong Provincial People’s Hospital (approval No. XJS2021-019-01; approval date: July 6^th, 2021). Informed consent was waived in this retrospective 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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