Routine radiography following chest tube removal in surgical patients: a systematic review
Review Article

Routine radiography following chest tube removal in surgical patients: a systematic review

Muralie Vignarajah1, Lucas Ilic2, Anood Alqaydi3, Bram Rochwerg4,5, Andrew Giles6

1Department of Medicine, Queen’s University, Kingston, Ontario, Canada; 2Department of Health Sciences, McMaster University, Hamilton, Ontario, Canada; 3Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; 4Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; 5Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; 6Division of Thoracic Surgery, Department of Surgery, Queen’s University, Kingston, Ontario, Canada

Contributions: (I) Conception and design: M Vignarajah, B Rochwerg, A Giles; (II) Administrative support: M Vignarajah, L Ilic; (III) Provision of study materials or patients: M Vignarajah, L Ilic; (IV) Collection and assembly of data: M Vignarajah, L Ilic; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Andrew Giles, MD. Division of Thoracic Surgery, Department of Surgery, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L2V7, Canada. Email: Andrew.Giles@kingstonhsc.ca.

Background: Following chest tube removal, the utility of routinely obtaining a “post-pull” X-ray is unclear, and practice patterns vary widely based on institution. The objective of this review is to determine whether routine post-pull X-rays, as opposed to imaging guided by clinical assessment, leads to differences in patient-important outcomes.

Methods: We performed a systematic review and meta-analyses and searched OVID Medline, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from inception, as well as explored citations from recent systematic reviews, for studies examining adult patients admitted to a surgical service, who had chest tubes placed for any indication, and examined those who received a routine post-pull X-ray compared to those who did not. Pediatric studies were excluded. We pooled data using a random effects model and presented data as mean difference (MD) with 95% confidence intervals (CIs). We assessed risk of bias with the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tool for non-randomized studies and the Revised Cochrane Risk-of-Bias Tool for Randomized trials (ROB-II) tool for randomized trials. We assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results: Of 3,069 citations, we included 8 studies (n=3,148). Of these, only one was a randomized trial. Pooled data of non-randomized studies showed that omitting a routine post-pull X-ray had an uncertain effect on length of hospital stay [MD 3.60 days fewer (95% CI: 8.46 days fewer to 1.25 days more)], very low certainty of evidence, and had an uncertain effect on the duration of chest tube placement [MD 0.83 days fewer (95% CI: 1.65 days fewer to 0.02 days fewer)], very low certainty of evidence.

Conclusions: The current data regarding the clinical utility of post-pull X-rays is poor and further high-quality studies are needed.

Keywords: X-ray; chest tube; thoracostomy; post-pull; radiograph

Submitted Sep 17, 2025. Accepted for publication Dec 10, 2025. Published online Feb 26, 2026.

doi: 10.21037/jtd-2025-1644

Highlight box

Key findings

• This study demonstrates that there is currently poor evidence in support or against the use of routine post-pull X-rays.

What is known and what is new?

• Currently practice patterns are variable among surgical centres regarding the use of post-pull X-rays.

• This manuscript further highlights the poor quality of evidence in this area, with very few studies directly answering this question, and only one randomized controlled trial.

What is the implication, and what should change now?

• The use of post-pull X-rays remains controversial and may or may not influence patient important outcomes.

• Additional randomized controlled data is needed is to address this highly prevalent practice question.

Introduction

Chest tubes play an important role in the evacuation of the pleural cavity following intrathoracic intervention. Chest tubes enable the removal of air, blood, and lymphatic drainage and ultimately allow for improved lung aeration (1). A common complication of chest tube insertion is improper positioning, leading to inadequate pleural space drainage (2). For this reason, obtaining a chest X-ray following chest tube insertion is critical to ensure that it is positioned in its most optimal location (3). However, the utility of routinely obtaining a chest X-ray following chest tube removal (a “post-pull X-ray”) is unclear, and practice patterns are widely varied.

The proposed benefit of obtaining a post-pull X-ray is to determine if the process of chest tube removal inadvertently led to the introduction of air into the pleural cavity and facilitated the formation of a pneumothorax. However, several studies have identified that the rate of re-intervention on these inadvertent pneumothoraxes is low (4-6), and so the importance of detecting them is unclear. Not performing routine post-pull X-rays may have the benefit of reduced length of hospital stay, reduced hospital costs, and reduced rates of unnecessary re-intervention. The objective of this systematic review is to examine whether obtaining routine post-pull X-rays influences key clinical outcomes in surgical patients. We present this article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1644/rc) (7).

Methods

Search strategy

We registered the protocol for this review on Prospective Register of Systematic Reviews (PROSPERO) on 29/01/2024 (CRD42024507544). We searched OVID Medline, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until Jan 24th, 2025 for studies examining adult patients, admitted to a cardiothoracic or trauma surgery service, who had chest tubes placed for any indication, and on removal compared outcomes of those who received a routine post-pull X-ray compared to those who did not. We also manually examined citations from recent systematic reviews. Surgical intervention did not have to be performed for the study to be included in the review. We excluded systematic reviews, case series, case reports, conference abstracts, and studies that involved children. Keywords included “chest tube”, “thoracostomy”, “chest drain”, “pleural catheter”, “withdrawal”, “radiography”, and “chest X-ray”. The full search strategy is shown in Appendix 1 and was generated with the assistance of a research librarian. Title and abstract screening were performed first followed by full-text screening, both in duplicate (M.V., L.I.), using Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia). Reasons for exclusions were documented at full-text review and any disagreements were resolved by a third-party examiner (A.G.).

Data extraction and analysis

We focused on the outcomes of re-intervention rate (repeat thoracentesis or chest tube re-insertion) as well as 90-day mortality, length of hospital stay, total duration of chest tube placement, incidence of post-pull pneumothorax, incidence of any post-pull X-ray abnormality, incidence of any symptoms following chest tube removal, and hospital readmission rate. Additional data extracted included year of publication, country where the study was performed, type of research study, individual study inclusion and exclusion criteria, sex of included patients, number of males and females in each study, mean age of participants, and study indications for chest tube placement. The Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tool (8) was used to assess risk of bias in the included non-randomized studies and the Revised Cochrane Risk-of-Bias Tool for Randomized trials (ROB-II) tool (9) was used for the single randomized controlled trial. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) (10). Data extraction and risk of bias assessment were done in duplicate (M.V., L.I.), with a third party (A.G.) used for any disagreements. Dichotomous outcomes are presented as risk ratios (RR) and continuous outcomes as mean differences (MD), both with 95% confidence intervals (CI). DerSimonian and Laird random effects model and inverse variance were used, and meta-analysis was completed using RevMan 5.4 (Cochrane Collaboration, Oxford, UK) software. Non-randomized and randomized data were examined independently. Statistical heterogeneity was assessed using a combination of the χ2 test, the I2 statistic, and inspection of the forest plots. For continuous outcomes, medians and interquartile ranges were converted to mean and standard deviations, using an online calculator based on research methodology from Shi et al. (11), and Luo et al. (12). When data did not include measures of variance [i.e., standard error of the mean (SEM), standard deviation (SD)], we did not perform pooling and instead compared rates of outcomes using a two-tailed independent t-test (significance set at P<0.05).

Results

Included studies

Of 3,069 citations, we assessed 29 full-text articles and ultimately 8 studies (n=3,148) were included in the review (Figure 1) (13-20). Five out of eight studies were retrospective cohort studies, two out of eight studies were prospective cohort studies, and one study was a randomized controlled trial. Meta-analysis was performed only on the non-randomized studies. Overall, we judged six out of seven of included cohort studies to be at serious risk of bias, one out of seven cohort studies to be at moderate risk of bias (Table S1). The single randomized controlled trial demonstrated moderate risk of bias.

Figure 1 PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Pooled outcomes

Pooled analysis of three studies showed that omitting a routine post-chest tube removal X-ray may be associated with decreased length of hospital stay [MD 3.60 days fewer (95% CI: 8.46 days fewer to 1.25 days more)], very low certainty of evidence (Figure 2). Omission of routine post-pull X-rays had an uncertain effect on the duration of chest tube placement [MD 0.83 days fewer (95% CI: 1.65 days fewer to 0.02 days fewer)], very low certainty of evidence (Figure 3).

Figure 2 Length of hospital stay following chest tube removal. CI, confidence interval; CXR, chest radiography; df, degrees of freedom; IV, inverse variance; SD, standard deviation.
Figure 3 Duration of chest tube placement. CI, confidence interval; CXR, chest radiography; df, degrees of freedom; IV, inverse variance; SD, standard deviation.

In both the X-ray omitted group and in the routine X-ray group, the incidence of post-pull pneumothorax was found to be low [1.22% (11/905 participants) vs. 5.97% (80/1,340 participants)], and there was no statistically significant difference between the two groups (P=0.15) (Figure S1). The incidence of any X-ray abnormality was 5.79% (72/1,244) in the omission group vs. 30.66% (561/1,830) in the routine X-ray group, again not statistically significant between the groups (P=0.07) (Figure S2). In addition, the number of patients who were symptomatic after chest tube removal was not found to be significantly different in the X-ray omitted and the routine X-ray group [7.35% (68/925) vs. 3.16% (44/1,393), P=0.95] (Figure S3). Low mean re-intervention rates were also observed in both the omitted X-ray group and in the routine X-ray group [1.85% (23/1,244) vs. 3.06% (56/1,830), without statistical difference (P=0.60), Figure S4]. Both groups also had low rates of hospital re-admission [0.38% (2/526) vs. 0.13% (1/796), again without statistically significant difference between the two groups (P=0.49), Figure S5]. Furthermore, none of the included studies reported 30- or 90-day mortality. Table 1 describes a summary of findings and certainty of evidence for each outcome. GRADE assessments are shown in Table S2.

Table 1

Summary of results

Items Furák (13), 2014 Goodman (14), 2010 Heidel (15), 2024 Mandegar (16), 2007 McCormick (18), 2002 Whitehouse (19), 2009 Zukowski (20), 2022 Matei (17), 2024
Control number of
participants, n		 50 387 93 157 703 25 377 63
Intervention number of participants, n 98 221 229 158 297 49 56 185
Patient population Patients undergoing uncomplicated lobectomy with single chest tube inserted Patients with thoracic trauma admitted to trauma service with chest tube placed Patients undergoing elective pulmonary resection Patients undergoing cardiac surgery Patients who underwent coronary bypass graft or valve surgery Patients who had undergone thoracic surgery and had thoracostomy tubes inserted at operation Patients underwent non-cardiac thoracic surgery, requiring postoperative chest tube drainage Patients who underwent elective lung resection
Study design Retrospective cohort study Retrospective cohort study Retrospective cohort study Randomized controlled trial Retrospective cohort study Prospective cohort study Retrospective cohort study Prospective cohort study
Inclusion criteria Insertion of single chest drain following lobectomy Procedural classification code indicating chest tube insertion Aged at least 18 years old and underwent a lung resection for both benign and malignant indications via VATS, VATS converted to an open approach, or thoracotomy Cardiac surgery patients Coronary bypass grafting or a valve operation by median sternotomy Undergone thoracic surgery and had thoracostomy tubes inserted at operation Patients undergoing noncardiac thoracic surgery requiring postoperative chest tube drainage Patients were all aged >18 years, required intraoperative chest tube placement
Exclusion criteria – Intraoperative chest tube removal, chest tube remaining in place at time of death Insufficient data, lung volume reduction surgery/bullectomy/pneumonectomy/intrathoracic access needing median sternotomy, discharge with a chest tube, in-hospital and pre-follow-up mortality, patients without routine follow-up Patients who died in recovery room or while still had chest tube in place Death in the cardiovascular recovery unit or death with chest tubes in place – Chest tube duration of more than 14 days, need for mechanical ventilation for more than 3 days, death during index admission not directly related to chest tube management, placement of a tunneled intrapleural catheter, joint operation with a nonthoracic surgery service who assumes primary care of the patient postoperatively, a prolonged air leak requiring endobronchial valve replacement, and patients undergoing pneumonectomy Patients undergoing urgent or emergent surgery and those undergoing pleurodesis, and those with prolonged air leak requiring discharge with chest tube
Country Hungary United States United States Iran United States United Kingdom United States Canada
Length of stay, days
   Control – 9.1 (0.61) 5 (2.3) – – – – 3.18 (1.59)
   Intervention – 1.5 (0.2) 3 (1.5) – – – – 1.98 (0.82)
Chest tube duration, days
   Control 3.7 (1.5) 5.7 (0.19) 3 (1.5) – – – – –
   Intervention 3.8 (1.5) 4.2 (0.18) 2 (1.5) – – – – –
Re-intervention rate (%)
   Control 6 8.53 1.1 1.91 1.85 – 0.53 1.59
   Intervention 7.14 0.90 3.06 2.53 0.67 – 1.79 0
Postpull pneumothorax (%)
   Control – 11.1 2.15 1.27 4.69 – – –
   Intervention – 0.45 1.75 0.63 1.68 – – –
Abnormal postpull X-ray (%)
   Control 50 25.84 3.23 3.18 40.4 – 33.16 30.16
   Intervention 46.94 0.90 3.49 3.16 3.70 – 0 –
Symptomatic post removal (%)
   Control – – 0 4.46 1.14 – 3.71 23.81
   Intervention – – 14.41 12.03 4.71 – 3.57 –
Readmission rate (%)
   Control – – 0 – 0.14 – – –
   Intervention – – 0.87 – 0 – – –

Data are presented as mean (SD) unless otherwise indicated. SD, standard deviation; VATS, video-assisted thoracoscopy.

The single randomized controlled trial (16) showed a low incidence of post-pull pneumothorax [0.63% (1/158) vs. 1.27% (2/157) in the routine X-ray group], and low incidence of re-intervention [2.53% (4/158) vs. 1.91% (3/157) in the routine X-ray group].

Discussion

This systematic review and meta-analysis aimed to investigate whether the routine use of chest X-rays post chest tube removal leads to improved patient outcomes in surgical patients. We included studies that directly compared patients who had received routine post-pull X-rays with those who did not. Overall, there were no major differences between the two groups in terms of re-intervention rate, with either chest tube reinsertion or thoracentesis. We also found that very few studies examined key patient outcomes such as length of hospital stay, 90-day mortality, or hospital re-admission rate. In addition, most included studies were of serious risk of bias and only one of the included studies was a randomized controlled trial.

Key outcomes

We found that omitting routine X-rays has an uncertain effect on length of hospital stay and omission of routine chest X-rays does not have a clear effect on duration of chest tube placement or re-intervention rate. The number of patients who were symptomatic following chest tube removal was low in both the routine and non-routine chest X-ray group. We did not find any studies examining impact on mortality. The overall quality of evidence is poor and definitive statements regarding the benefits or drawbacks of routine radiography cannot be made.

Existing literature

A similar systematic review examining patients undergoing cardiothoracic surgery, identified that many clinically significant pneumothoraxes are symptomatic for the patient (21). The authors concluded that the incidence of re-intervention following chest tube removal is low and that routine use of a post-pull X-ray is not needed. Several other studies have also shown that the need for re-intervention following chest tube removal is low, such as in blunt trauma (22), post-esophagectomy (23), and in general non-surgical patients requiring chest tube placement (24). This low incidence of re-intervention has been further observed in the pediatric population (25-27).

Our study differs from previous reviews, in that it had a more focused research question with tightly controlled inclusion and exclusion criteria, and a robust evaluation of individual studies’ risk of bias. We examined only adult patients who were admitted under surgical services and only included studies that directly compared outcomes between those who obtained a post-pull X-ray to those who did not. This led to the exclusion of several more subjective studies, such as those that examined single-surgeon experiences or gradual changes in institutional practice patterns.

Strengths and limitations

Strengths of this review include a specific clinical question, a pre-registered review protocol, a comprehensive search strategy supervised by a librarian, article screening and data extraction performed in duplicate, comprehensive risk of bias assessment for all included studies, and use of GRADE certainty of evidence to contextualize findings. Limitations of this review include the small number of studies assessing key patient-important outcomes and many of the included studies having a high risk of bias. In addition, due to a low number of included studies, we were unable to perform meta-analysis for many of the outcomes of interest. Lastly, we did not assess other patient-reported outcomes, such as quality-of-life, as part of this review.

Implications of study

Chest X-rays are widely used tools in healthcare settings. However, because of their widespread use, obtaining chest X-rays in a hospital setting can be time consuming for hospital staff, particularly for nursing, X-ray technologists, and radiologists, and may ultimately lead to prolonged length of hospital stay. The omission of unnecessary chest X-rays can therefore likely lead to significant financial benefits to the hospital system (28). Our study aimed to determine if the routine use of chest X-rays following chest tube removal benefited patients. Omitting routine chest X-rays post chest tube removal may be safe however further high-quality evidence in the form of randomized trials is needed. Future studies should be performed with key outcomes such as mortality, length of stay, and re-intervention rate covered and also should examine cost effectiveness and patient quality of life measurements. In particular, focusing on post-lung resection patients, who are at the highest risk of air leak and pneumothorax. This group of patients would greatly benefit from further exploration of this prevalent question.

Conclusions

The evidence regarding routine use of post-pull X-rays is poor. Further randomized controlled data on the subject are needed, given how prevalent the use of post-pull X-rays are and how varied practice patterns are. Due to the low quality of evidence definitive statements cannot be made on the safety of omitting post-pull X-rays, or whether post-pull X-rays influence length of hospital stay.

Acknowledgments

We would like to thank Angelique Roy and Abdul Kareem from the Department of Health Sciences of the Queen’s University Library for their assistance with developing the search criteria and running the literature search.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1644/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1644/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-2025-1644/coif). A.G. reports that he sits on the advisory board and has speaking engagements for Astra Zeneca, Merck, Bristol Myers Squibb and has an unrelated research grant from Roche. The other 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.

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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Cite this article as: Vignarajah M, Ilic L, Alqaydi A, Rochwerg B, Giles A. Routine radiography following chest tube removal in surgical patients: a systematic review. J Thorac Dis 2026;18(2):169. doi: 10.21037/jtd-2025-1644

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